I first became aware of the Long-Acting Injectable Buprenorphine (LAIB) six years ago at The Australasian Professional Society on Alcohol and Other Drugs conference.

I clearly remember thinking, as Professor Nick Lintzeris spoke, what an incredible game changer this could be for the clients at First Step on the pharmacotherapy program, particularly those on stable suboxone (buprenorphine). I was then super disappointed to hear that it had not even begun a trial phase.

Fast forward a few years, and I heard murmurings that the LAIB had passed trials and was being rolled out into the community treatment space. Despite its availability, I, and several of my clients, felt hesitant about something that had only been proven ‘on paper’.

For many clients who had been on pharmacotherapy programs for a long time it presented an enormous decision.  On one hand, attending a pharmacy daily or weekly posed a significant risk – they might bump into someone they know, what if they missed a dose, what if they were judged by the pharmacist?  On the other hand, moving to a 28 day cycle was intimidating in itself – attending the pharmacy is an important link to their community, and sometimes, the pharmacist might be the most regular human contact some clients have.

We began small by providing it to people initiated elsewhere, or clients who specifically requested it. It was at this point that I met Stacey (not her real name), the patient whose story significantly shifted my opinion of this treatment option.

Stacey is a 59 year-old woman who started using opiates in her mid-teens and had been on the methadone program for more than 20 years. Throughout this time, she had continued to use heroin and it had continued to cause issues in her life.  In June 2020, Stacey admitted herself into a residential withdrawal unit to transfer from methadone to the LAIB program, and we picked up the management of this after she left. 

When I first met her, she was demanding, unreasonable and difficult to engage with because of her brittle manner.  Our time together over the first three months largely consisted of her telling me what was wrong, and what she wanted me to do to fix it.

Then something shifted. Slowly, and quite subtly, at first.

One of the things we speak about at First Step is the idea of ‘incremental whole –of-life improvements’, and this description perfectly described my interactions with Stacey.  On paper, she had only had a slight shift – she had remained on pharmacotherapy, albeit a different type and delivery system.  But the effect of this in her life was profound.

The first significant change we noticed was attitude. Stacey was more patient, understanding and could recognise situations around her that were affecting more than herself. She was more polite dealing with people, and the staff recognised this.

From there things just seemed to ‘incrementally improve’.  Stacey started to dress differently, as she described, “more appropriate for my age”.  And she began planning, weeks and months ahead for things, something she had previously been unable to do.

Over the next couple of months, Stacey would excitedly attend appointments, telling me with an enthusiasm I didn’t believe she had, that she was studying for her Learners, with the view of getting her license for the first time.

It is important to note, LAIB is not a ‘miracle cure’.  Stacey committed a tremendous amount of hard work to achieve everything that she did.  A clever psychiatrist once told me, ‘pills don’t teach skills, but they give the brain a chance to learn them’, and this was never clearer than with Stacey.

It was a humbling experience watching an adult woman’s life change slowly before my eyes, watching her discover new things she had not thought herself capable of previously.

Haydn Salomons, Clinical Care Coordinator

11 March 2022

During debate on Fiona Patten's proposed drug law reform bill, Bernie Finn MP proposed the death penalty for drug dealers ("drug lords"):

"I would be very happy to administer [the death penalty] myself in fact if it came to that, because quite frankly [drug lords] disgust me in a way that is hard to put into words: https://lnkd.in/gD97uTGV

At First Step we wonder if Mr Finn would consider killing the CEOs of big tobacco, big pharma and alcohol companies whose products are responsible for far more deaths than all illicit drugs and vastly more burden of disease: https://lnkd.in/gzbakVr7

Does Mr Finn perhaps even drink alcohol? Does he or has he ever smoked tobacco? Would he now consider, himself, finding those people that sold these drugs to him (alcohol and nicotine) and ending their lives?

The point here is not to score points or poke obvious holes in radical arguments, but rather to point out what is going on here.

It's called stigma.

There is a stigma around the use of illicit drugs. In Mr Finn's case it is directly at 'drug lords', but it certainly spills over to drug users, particularly people who inject drugs.

First Step recently met with the director of a secure facility for children (funded and run in one of the states of Australia), basically a temporary psych ward for kids at great risk. Practically all the kids in this facility have mental health treatment needs and addiction treatment needs and many are the victims of sexual exploitation. And guess what percentage of the kids are in child protection/out-of-home-care? 100% One hundred percent! These are literally the most vulnerable people in Australia, overly representing indigenous kids, near universal history of childhood abuse, including sexual abuse. A good many of these kids will go on to sell drugs at some point. What would Mr Finn like to do with them at that point, young people some of whom have never known a mother's or father's love. Many of these kids, if they had not found in illicit drugs a reliable source of dopamine stimulus (ie. temporary happiness) would have taken their own lives and might still.

We will invite Mr Finn to visit First Step, to see a little of the other side. You gotta try.

#mentalhealth #lifewithaddiction #firststep #healthnotharm

Patrick Lawrence Chief Executive Officer

22 February 2022

On Wednesday I had the great privilege of speaking at Fiona Patten's press conference at Victorian Parliament House in favour of her bill to decriminalise the possession of illicit drugs for personal use (small quantities). We have had great coverage of the event with Fiona's, Baden's (our former client and now amazing peer worker) and my won words repeated around the country and overseas. Here is a transcript of my address to the press for anyone interested. The bill will be debated and voted on in early March. Spread the word and make a noise (including by writing to your local member at www.decrim.com.au).

At First Step we work in a very challenging environment made infinitely harder by the world’s greatest public policy failure. The greatest impact of our current drug laws is felt not by the recreational drug user but people who have survived childhood poverty, sexual abuse, poverty, homelessness and the absence of love and bonding. In my 20 years working in the alcohol and other drug sector I’m yet to meet a single person dealing with significant drug use or addiction, who is not using those drugs to manage their pain and trauma. Most of us, if we had the tools, would move mountains to stop a child being harmed, we'd leap Paddy-Dangerfield-like into the surf. At what age does a human bein g become unworthy of empathy and protection?

Enable police to direct people to education, treatment and support, instead of arresting them. That’s actually all we’re asking for. Yes, it will need resourcing, but can you imagine the funds that would be freed up from the criminal justice system. If you create a society where the most vulnerable receive health not harm, well that benefits every single one of us. Everybody deserves every chance to turn their lives around, and this reform proposal aims to do just that.

The law didn’t break Baden’s cycle of addiction and trauma. Treatment did. Welcome, empathy and hope did. And of course Baden's own courage and resilience. The evidence tells us that Baden's example is typical, and that the proposed changes to the diversionary powers of the police will not result in an increase in drug use. Just an increase in treatment and new beginnings.
If we could design it again, we would never build a system like this. Thousands of people in prison and the courts, and recreational as well as heavy users receiving criminal sanctions. So it’s up to the people in this place of great power and privilege to listen to lived experience, study the evidence and talk with the experts. To say “It’s not a priority”. . . well, that’s not an answer.

Be tough of crime, but let’s redefine what a criminal is. Because currently it’s 40 per cent of the population and that’d be funny if it weren’t also tragic.

Here is the press conference in full:

#mentalhealth #lifewithaddiction #firststep #healthnotharm

Patrick Lawrence Chief Executive Officer

At this time of year, it would be remiss to not say something like, “Well, it’s been a very challenging year, but we’ve survived and learnt a great deal”, and then reflect on organisational achievements.
So, I’m going to be remiss!

Billed as a time for celebration, Christmas is also a time of societal pressures, social anxiety, revisiting old family wounds, sometimes fueled by alcohol. We would love for all gatherings of family and friends to make the words of Tim Minchin (‘White Wine in the Sun’) true for all:

Wherever you are and whatever you face
These are the people who'll make you feel safe.

But we know that this is not universal. Not by a long way. Poverty, dislocation, substance use and abandonment don’t make for a good start in life, and they don’t make for a good Christmas either.

As we say at First Step, ‘everybody deserves every chance to turn their lives around’, and this is just as true for every family, every friendship group and every support network.

It is our Christmas wish to all our clients, all our staff and all our supporters that you make of this summer break everything that you can. Be kind, listen, hug when the hugs are good, give, receive. During and after lockdowns we’ve all been re-evaluating life a little – let’s do that for Christmas too and make the most of every social connection we have.

And if you know someone who is going to be lonely at this time, please reach out to them.

Please enjoy our Christmas Newsletter.

Patrick Lawrence Chief Executive Officer

Relationship rebound - a ResetLife client story

I grew up in a typical Aussie home in the ’80s. Big sprawling house. All the neighbourhood kids hanging out together. My three sisters and twin brother playing at the pools in the summer. Family trips to Bright. I had a great family life and a fabulous childhood.

Until I was 7, when my mum left.

In my early-teens, some issues started to emerge for me – even though I looked masculine, that’s not what was inside me. I’ve always had a feminine side.

I was nervous about being around people and fitting in, so when I started going to parties, I found that alcohol could be the lubricant for confidence. But instead of fitting in, I would end up the joke of the party. Once, my brother shaved off my eyebrows when I was passed out!

My drinking accelerated after I finished school, and this was the start of 30 years of alcoholism.

There were a few years in my late 20’s when I felt I was getting my life together. I met a woman, and we had a child together. I went to University to study and was drinking only on the weekends.

But this didn’t last long and soon I was alone, lonely and miserable – and drinking every night. Twice, I lost my license and had to explain to my daughter what the ghastly interlock device on my car was. She was too young to understand, but I was so humiliated.

The first time I tried to take my life, I was admitted to a psychiatric unit and was diagnosed with Schizophrenia. Thirty years of alcohol abuse really pickled me. But I didn’t stop. Until one evening when providence intervened, and I thought: ‘Why am I drinking this? This is foul. What am I doing?’ And from that moment on, I never drank again.

Unfortunately, I replaced alcohol with drugs to fill the void, and that didn’t turn out so well for me. The drugs interfered with my Schizophrenia medication, so I decided to stop taking the meds. I began to hallucinate, I was paranoid, I wasn’t showering, I wasn’t eating, and my apartment had a cockroach infestation. I barricaded myself at home and thought there was a death squad out to kill me. I was frightened and couldn’t trust anyone.

I had hit rock bottom. My dad came, and so did the Crisis Assessment Team. Enough was enough.

Now, I am on the right medications every day, which means I can speak fluently without any voices in my head. I have the ResetLife Program at First Step, which helps me keep accountable to my own abstinence journey. And a long list of people to call for support.

ResetLife taught me about the physiological side of drug abuse. That my brain tried to keep me in addiction, but the longer I was into recovery, the more the logical brain took over and I could rationally consider, ‘Why would I want to take drugs when everything is working right now? Why would I want to take drugs when all of my relationships have recovered?’

All of my important relationships have rebounded.

I have reconnected with my mum. My sisters are more active in my life. My dad continues to be my rock. But most importantly, the relationship with my daughter has flourished. It’s incredible! She is the pride of my life. She accepts me for who I am, and we spend hours on long walks where she shares her stories with me. I feel so privileged that she trusts me! And so lucky to have great people in my life supporting and mentoring me.

I feel so good.

And now I want to get back into society – to work, study and volunteer. My graphic art has been a constant outlet over these years, but I really love writing so am looking at doing a writing and editing course in 2022. And I want to get involved within my local LBGT community so I can give back there too.

Everyone who sees me says, ‘You look so much better’. I have recovered.

Maddie ResetLife Client

Silver linings by Dr Basanth Kenchaiah

As I think about a COVID-19 normal world, I am planning to visit family in India, which has been long overdue.

The second wave in India was so intense, almost everyone in my family contracted the virus, many were hospitalised, and two passed away.

Throughout this period, the discussion between friends and family was consumed with concerns for our loved ones. Phones were constantly ringing. We were looking for medical supplies, beds and even cremation facilities as they were hard to find.

It was distressing to be so far away.

Things are looking much better in India, though there are concerns about a third wave with the new variant. I am really looking forward to going back to connect with loved ones.

While Melbourne has achieved the dubious distinction of the most locked down city in the world, and admittedly we have all struggled, I believe we are very lucky to live here. We have had relatively few deaths and our vaccination numbers are high. I find it hard when I come across people who dismiss the impact of the pandemic, even after I have shared my personal stories.

Generally, we would not disclose personal information during consultations, but COVID-19 has been one instance where patients have enquired about us, and our families, and the sharing of some stories have been a benefit to everyone, and a great equalizer.

One of the silver linings for the community has been the wide roll-out of telehealth which is now being made permanent. It has transformed healthcare in a significant way with numerous benefits.

There are limitations and our approach will have to adapt to them. For example, on occasion, all I see is a patient’s face, so it is difficult to ascertain what physical state they might be in. Do they have side effects such as tremors or weight gain from the medications? Where I would once observe the subtleties, I now have to use different skills. Some telehealth etiquettes need to be established so that the consultations don’t occur when people are driving around or sitting in a toilet!

The other silver lining, for me personally, was the birth of my son a couple of days before our first lockdown. At first, I was concerned about the impact of being born into lockdown, but soon realised what a remarkable bonding opportunity I had, thanks to the lockdowns!!!

As he starts exploring the new normal we live in, and we all start celebrating the Christmas spirit, welcoming a New Year, I hope you can reflect on this year, and also see the silver linings.a

Dr Basanth Kenchaiah Psychiatrist, First Step

A game changer for First Step

We are excited to announce our new partnership with 3 Phase Marketing (3PM), supported by RentBuyIt.com.au.

3PM are an award winning, boutique, digital marketing agency with a big heart and an amazing ability to quickly understand complex social issues.

They get us, they believe in our work, and they care about our clients.

3PM were introduced to us by RentBuyIt.com.au Director, Con Nakas, who saw the potential in this partnership to be a gamechanger for First Step. Con put philanthropy in action by connecting time, money and people for the greater good.

First Step receives no state government funding to deliver our health services. We rely on the generosity of our community to provide care to our unfunded clients, fill the funding gaps, and support innovation and growth.

Today, the sector is not able to meet demand, let alone what we anticipate it will need over the next 10 years.

This partnership aims to reach a wider audience than ever before, improve our financial sustainability, and grow our advocacy network. Our objective is to find people who believe what we believe, who admire the strength it takes to take the first step towards recovery, and are proud to assist people taking the second and third steps.

This will be a game changer for First Step.

Check out our first campaign together, the First Step Gift Shop.

In our Gift Shop, select a gift option to donate, instead of buying Christmas gifts, and we will then send you an eCard that you can print or email to your loved ones. Give a meaningful gift this Christmas.

We are very grateful to RentBuyIt.com.au and 3PM for their partnerships.

This is the kind of law I want to practice by Sasie Wijewardana

I wasn’t going to go into law. I was going to be a teacher. I come from a family of teachers – my brother is a teacher, my parents are teachers, their siblings are teachers. I wanted to do something that involved working and interacting with people.

My year 12 teacher suggested I apply for law, but I wasn’t too fussed, because in the back of my mind, I was going to be a teacher.

Needless to say, I’m not a teacher. And in fact, last week sat my final law exams!

About a year ago, I saw in a Facebook group a call out for First Step Legal volunteers. I researched the First Step model and what struck me was that people in Sri Lanka (which is where my family is from) with mental health issues don’t have access to appropriate resources and services, and I was in a position to positively impact this for people here in Melbourne.

I joined the team as a volunteer and quickly learnt that the theoretical knowledge taught at university is different from the practical application. Sometimes we deal with heavy subject matter that takes an emotional toll, but the lawyers are extremely approachable and prioritise supporting the volunteers, which is really comforting.

Spending time at First Step and seeing how closely we work with people with mental health and addiction issues, I thought, ‘yes, this is the kind of organisation I want to work with. This is the kind of law I want to practice.’

I get to work hands on with people, to speak to them and hear their stories. What I’ve seen time and again, is that their circumstances and experiences have led them down the path where they might offend. And I’ve also seen that the way we treat offenders is just not right. We disregard them, throw them in jail, don't care about them. And many people have already gone through such unfortunate circumstances in their lives.

I have now stepped up into the role of Legal Case Manager at First Step Legal, where I am responsible for managing client files, supporting the lawyers and overseeing the volunteers. I am grateful for the mentoring and guidance I have received from the team, and in my new role want to ensure that our volunteers have a positive, supported, experience.

Sasie Wijewardana Legal Case Manager First Step Legal

8 September 2021

Hypothetical Case Study of a client with co-occurring needs (including mental health, alcohol and other drugs and other support needs) attending a future Local Mental Health and Wellbeing Service

Preamble

This case study was written to provide another kind of conversation about how the new Victorian Mental Health Centres (see below) might provide whole-person support (including for alcohol and other drug treatment needs). It is hoped that it will indicate how several of the recommendations in the final report of the Royal Commission into Victoria’s Mental Health System (RCVMHS) relating to integration between alcohol and other drug support and mental health, might manifest in practice. The perspective is from one of the proposed Adult and Older Adult Local Mental Health and Wellbeing Centres (Royal Commission has mandates approx. 50 in Victoria)

The Alcohol and Other Drug (AOD) sector is aware that much of the work of the Local Centres will be in the mild-to-moderate space, and feels that basic AOD Counselling (or better still, integrated counselling that includes AOD support) should be part of the Local Centres service offering. As complexity and comorbidity increase, most people expect the 3 models of integration outlined in the final report of the Royal Commission to come to the fore: multi-disciplinary teams, co-location and partnership. This case study depicts what the AOD sector would describe as moderately to highly complex, without being severe.

Most of the principles outlined in this hypothetical case study would apply just as much to an Area MH & WB Centre, but are envisaged in this case study for a Local Centre.

Damien (hypothetical client)

DAY: 1

Damien, a man in his 30s, experienced a high number of traumatic childhood events including abuse and neglect, homelessness and poverty. As an adult he has occasionally experienced homelessness and often experienced of unemployment, though Damien is currently housed and working. He has been drinking heavily and using illicit drugs on at least a weekly basis since his teens. Damien is consistently very unhappy and believes that he is in grave danger of losing his relationships, his job and more if he can't improve his mental health and at least reduce his drug and alcohol use. After thinking about seeking help for years he takes a deep breath one day and steps inside his Local Mental Health and Wellbeing Centre (the ‘Centre’).

Damien mills around in the waiting room for a little while, trying to look at the various publications on the wall, but not taking anything in. After a couple of minutes a member of the welcome team finishes chatting with another client in the waiting room and walks over. Lenny, a paid staff member with a lived experience of mental illness who manages a team of volunteers in the Welcome Program, smiles broadly and introduces himself. Damien is surprised to have been approached, but it’s done with such gentleness and skill that he finds himself talking pretty freely. Lenny learns that Damien is here because of concerns about his own health (not that of a family member) and that he worries about his use of alcohol (that’s all he’s disclosed for now). Lenny says how nice it has been to meet Damien, and explains that he’d like him to have a chat with one of the assessment workers. He thinks it’ll be about a 10-15 minute wait. Damien is fine with that. Lenny gets him a coffee.

Fatima comes out to the waiting room, greets Damien warmly and ask him to come with her. They move into a spacious intake room with more printed materials/resources and a comfortable seating arrangement; casual but professional. Fatima explains that she’d like to note some things on her iPad as she talks with Damien and asks if that’s okay. He says it is. To do that, she explains, she will need him to sign the new patient form, and she points out that the form states that staff of the Centre have his permission to share his medical details with other staff members at the centre (in writing or verbally), but not with anyone else. The good thing about that, she explains, is that he won’t have to tell his story multiple times. Damien consents and signs.

NB. All client data is stored within the one Client Management System. Psychologists, doctors, social workers, AOD therapists etc, all record client data in a centralised system. The integration sought is not possible without a centralised/universal data system.
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A note on Fatima (assessment worker): Fatima has years of experience, as well as formal qualifications or training in 1) mental health, 2) substance use disorders and 3) psycho-social assessment and support. She is able to provide trauma-informed, person-centred care. Fatima has a dual role as assessment worker and then counsellor as she maintains contact with the clients she has assessed. She is fully capable of not only conducting initial whole-person assessment (including administering assessment tools for MH and AOD) but also delivering immediate interventions and advice. Her goals at this first meeting are:

- To ensure that Damien feels welcomed and respected at the Centre
- To begin to establish the norms of his relationship with her, and by extension the rest of the staff at the Centre: respectful, consultative, honest.
- To begin to paint a fuller picture of Damien so that she can learn if the Centre is the most suitable place for his care, and if so, who is the support team likely to consist of (of course this picture will grow and change over time).
- To get a quick win or two today in terms of advice, support and freebies (dental hygiene kit, MYKI cards, supermarket vouchers, relevant handouts, help him download a mindfulness app etc) as appropriate
- To begin to piece together and record the information that will be needed in the likely event of the formulation of a Care Plan for Damien
- To collect that data necessary for Damien’s care and for the Department of Health
- To have Damien leave feeling and being safe and connected.
- To have Damien completely across of the next steps and recommendations for the period of time before the next consultation (possibly in writing for his reference).
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BACK TO THE CASE STUDY

Fatima learns quite a lot about Damien in this initial session. With skill she encourages Damien to share his story, guiding only occasionally. She incorporates this listening approach with some clinical assessment tools also. She learns that Damien has occasional thoughts of self-harm, including a suicide attempt in his teens, and he describes himself as 'pretty sad a lot of the time.' In describing his childhood and adulthood she observes traits commonly associated with ADHD. She gleans information about his drug use (he didn’t raise that with Lenny in the waiting room) which it turns out is frequent, including periodically injecting drugs. She pauses to focus on that, learning about how, when, what and with whom Damien uses drugs. Because Damien seems comfortable with this focus Fatima decides to spend the likely remainder of the session today on harm minimisation education. She exhibits care and concern, not judgement, and discusses safer injecting practices, provides Damien with clean needles and syringes (she has them right there) and Nyxoid (a nasal spray delivery system for naloxone to treat opiate overdose). She asks if she can bring Lily in (peer harm min worker) for a couple of minutes to teach Damien how to use the Nyxoid properly. Damien is fine with that, and Lily undertakes a 10 min training in the room, explaining that he could save a friend’s life, and if he passes the training and the Nyxoid on, a friend could save his.

Both Damien and Fatima feel that this is enough for now. Fatima explains that she would like to make another appointment for him, this time with one of the centres GPs to look at his general health and drug use also, and assures him that she will attend at least part of that appointment. Fatima explains that now Damien will have a team of 2 here at the centre, and that it will likely grow bigger than that. She also explains that they will be here for as long as he needs them.

After Damien leaves, Fatima spends another 30 minutes writing up her notes, for herself, for the GP and for any future staff members who might need them. This includes an indication of possible future support needs:

- Ongoing integrated counselling including focussing on Alcohol and Other Drugs (provided by Fatima)
- Medical support for drug and alcohol use (possibly opiate substitution therapy)
- Clinical mental health support (eg. Mental health nursing, Psychologist, possibly psychiatry)
- Inpatient detox (this would be in partnership along a very warm referral pathway, eg. no retelling of his story, to an external AOD partner organisation). It’s too early to contact her assigned intake worker at the partner AOD agency, but she has a quick look at the wait list publicly available on the DirectLine website (she feels Damien is well into the contemplation stage of change).
- AOD support group, possibly LGBTQ+ (either one of the groups run at the Centre or NA or similar)

Because Damien has several support needs ('comorbidity') and his AOD use is consistently high, Fatima consults her supervisor regarding Damien’s suitability for care at the Centre. Due to the level of complexity that is emerging he may be too complex for the Centre, and should possibly be referred to the Area Adult and Older Adult Mental Health and Wellbeing Centre. Together they decide that given his current status as securely housed and also in employment, and the fact that he demonstrated cooperation and respect during his assessment, the level of risk demonstrated so far can be managed by the multi-disciplinary team approach put in place at the Centre. Between the team onsite (counsellor, mental health nurse, GP and others) and also through collaboration with the formal AOD sector (eg. for detox, specialist AOD groups and secondary consultation), there is a good chance that Damien and the team will be able to achieve incremental whole-of-life improvements for Damien over time, whilst helping him stay employed, housed and out of the emergency department.

Lastly, Fatima lists Damien for the next meeting of her multi-disciplinary team. It will be a brief mention as Damien is new to the centre, but she wants to flag that he may need a large team, and likely external referral also. Fatima consults the caseload list and assigns a care coordinator to him. The care coordinator, Kym, will be automatically notified by the system, and Fatima makes a mental note to have a brief chat also before the whole-of-team meeting. Being in the same multi-disciplinary team, Kym and Fatima’s offices are very close to each other and they usually bump into each other several times every day.
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A note on the multi-disciplinary teams: Because of its size this Centre has two distinct (and very similar) multidisciplinary teams, purpose-built for an inter-disciplinary approach to complex clients [the reason for multiple teams is to keep team size down for reasons of staff familiarity, logistics and focus on a not-too-large client cohort]. Individual disciplines communicate frequently with each other (eg. All the care coordinators know each other and collaborate to continuously improve care coordination at the Centre), but even more so staff know the members of their assigned multi-disciplinary team.

‘Complexity’ in a client is shorthand for a) a high severity of symptoms, and b) comorbidity - the client’s need for support across multiple areas (eg. MH, AOD and housing). Complexity is the expectation when a client attends the Centre, and new clients demonstrating complexity (or existing clients whose presentation becomes more complex) are fast-tracked for the development of an individualised support team including clinical and non-clinical elements. Each multi-disciplinary teams consists of one or more of each the following:

- GPs (with AOD quals/experience)
- Clinical mental health workers (eg. psychologists, mental health nurses)
- Family support workers (families engaged as early as possible)
- Peer AOD counsellors
- Peer mental health workers
- Care coordinators
- Social workers and/or psycho-social workers

Each Centre will have resources that must be shared across multi-disciplinary teams and the Centre generally due to expense, scarcity and level of specialisation, such as:

- Psychiatry
- Legal support (eg. Onsite clinics provided through a Health Justice Partnership arrangement with a local community legal centre)
- Support groups
- Onsite allied health clinics (likely through partnerships).
- Housing support workers (onsite clinics through partnership)
- Nursing (working with GPs)
- Intercultural workers
- LGBTQ+ workers
- Indigenous health workers
- Vocational therapists
- Family violence workers

Where possible and relevant to particular client, these staff should also be invited to whole-of-team meetings also.

Secondary consultation with the AOD sector and/or Area Centres is likely to be necessary for access to addiction physicians (FAChAMs) and addiction psychiatrists.

The purpose of designated ‘teams’ is to ensure a whole-of-person approach to care, and to put in place every necessary condition for team-work. It is essential that members of the team:

- Have the right mix of disciplines
- Are committed to the principles of teamwork including sharing risk
- Have weekly whole-of-team meetings
- Conduct case conferences with GPs and other staff as needed
- Know each other well enough to seek support, having scheduled but also ad hoc discussions as needed
- Contribute to the formation and implementation of Care Plans
- Are committed to a culture of learning and teaching across disciplines.

A multi-disciplinary team can increase the likelihood that gains made in one area (eg. AOD treatment) can be consolidated across other areas (eg. Social inclusion, mental health, housing), so that the client experiences incremental whole-of-life improvements over time.

Note: A new complex client does not necessarily get a large support team, but rather the disciplines are brought into the team as they are required, understanding that there is no hand-off, but rather an augmentation of the team. It is understood by all staff that people recover in the context of relationships (with the human beings who are providing professional support), and they commit to care for the client for as long as it is required, and as long as the Centre remains the appropriate venue for care.

Note also: Staff members who are part of a multi-disciplinary team may also support clients who are not deemed complex and have only one person in their Centre support team. Caseloads for individual practitioners are balanced for numbers, complexity of clients and level of involvement in care.
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BACK TO THE CASE STUDY

DAY 2:

Damien does not show up for his second appointment. Although he now has an assigned care coordinator (Kym) that Fatima has discussed him with, Fatima does the follow-up in this instance because Damien hasn’t met Kym yet. After two days of leaving messages, Damien finally answers the phone. After the initial assessment Damien was a bit overwhelmed by thinking about issues that he had been suppressing for a long time. Fatima engages Damien in a bit of Motivational Interviewing and psycho-education. She tells him that his reaction is totally normal; in fact it’s so normal that they even talked about it a little when he visited last time. “Didn’t make it any easier though,” says Damien and he and Fatima have a wry laugh. Fatima tells him that recovery (“That’s our fancy word for getting healthier and happier”) is non-linear (“That’s our fancy word to say that you’re going to have your ups and downs”). Fatima reminds Damien that he took the first, brave step to enter the Centre, explains in some detail what a consultation with the GP might entail and asks him if that is still what he wants. She waits through a long pause before Damien says yes, that is definitely still what he wants. Can he maybe come in today? Fatima is very familiar with the ways of working of the GP she had lined up and is certain he’ll squeeze Damien in for an opportunistic drop in. “How soon can you get here, she asks?”

Fatima makes a note in Damien’s file that she thinks he will benefit from some peer support and emails one of the peers to check his availability that afternoon.

LATER THAT DAY:

Damien attends and the Centre, checks in with reception. “Good to see you again Damien”, says the reception worker who Fatima had worded up to give Damien a little extra attention (that’s actually Damien’s first friendly word from someone since he left the Centre days ago; his smile is genuine). “Fatima will be right out.”

Fatima takes Damien to see Dr Anh Nguyen, makes the introductions and tells Damien she’ll catch up with him after the session. ‘Dr Anh’ is a General Practitioner with advanced skills training in medically assisted treatment of opioid dependence and other AOD training. A nurse pops into the room to do basic observations while Damien and Dr Anh chat (this is a drop in and things are a little hectic). It’s obvious to Damien that Dr Anh already knows quite a lot about him, and there is no backtracking or re-telling of his story. Fatima and Dr Anh complete a Mental Health Care plan for Damien including the need to access (onsite) clinical mental health supports in the form of a mental health nurse.

NOTE: General Practitioners are central to the delivery of AOD treatment in primary care.

WHAT’S NEXT:

Over the next couple of months Damien sees Dr Anh, Fatima and his mental health nurse Joe several times. His appointments (reminders, check-ins) are made and followed up by Kym (care coordinator) and he gets a support call about once a week from Bruce, a mental health peer who is also gay (it has emerged gradually that Damien is gay and that this is a cause of considerable stress with his family, and something that he largely keeps secret).

In week three Kym has lined up an appointment at the Centre with an intake worker from the AOD inpatient detox service (intake workers visit frequently as required; the care coordinators group appointments to make the most of the intake workers time). Kym is present throughout the appointment and has, ahead of time, negotiated and documented which aspects of Damien’s history he is happy to share with the AOD service. Nothing extraneous, just issue relating to risk, readiness and medical wellbeing. NB. Kym didn’t make the appointment until she was confident that Damien would pass the assessment (she knows the system inside out).

AFTER THAT:

Damien stays heavily involved in the Centre for 7 months. During this time Damien:

- Undertakes a week-long inpatient detox (external to the Centre), with Bruce checking in on him a couple of times over the phone.
- becomes a devoted group attendee (a LGBTQ+ AOD group through NA, Bruce took him to his first couple of sessions)
- commences buprenorphine treatment for opioid addiction (he and Dr Anh are planning to continue this for several months while he strengthens his community networks, improves his family relationships, and improves his daily exercise routine – the Centre has used brokerage funding to pay for 6-months’ membership of a local gym)

After a good chat with Damien weighing up pros and cons, Dr Anh slates Damien for discussion at the weekly whole-of-team meeting. He explains that they are shortly going to stop the buprenorphine treatment and monitor Damien’s progress. Some team members are nervous about this and Anh explains that he’s already scheduled an online secondary consultation with an Addiction Specialist (FAChAM) he knows well at the Statewide AOD service (with whom he does regular training). Anh won’t proceed without further advice and once again discussing Damien’s readiness with Damien himself. Bruce offers to step up his contacts if and when the treatment regime changes (and he’ll call him after this meeting for a quick check in).

Gemechu is Damien’s family support worker. Damien’s mum & dad have been attending a fortnightly online support group for families/loved ones organised through the Centre and Gemechu has established a high level of trust with them. Gemechu says he’ll get in touch with Damien and see if he wants Gemechu to help explain this transition to his family.

Fatima has been in the background of Damien’s care lately, but speaks up here. Does Anh think that, if this transition goes well, Damien might be in a good position to start psychotherapy to address underlying traumas. “I’ve got capacity”, chimes in Jan, the senior clinical psychologist in the team. The three schedule a time to do a case conference outside of the meeting. Jan goes on to engage Damien in a variety of modalities including CBT and DBT in processing issues of childhood trauma.

There are ups and downs, and in the end Damien needs to detox again and the plan to end buprenorphine is postponed a number of times All through that time Damien knows where to go, who to call, what to do and how to look after himself. He is always ashamed when he slides backwards, but there is no doubt in his mind that the Centre will always be there for him and he keeps coming back. Some historical legal issues surface from previous property crimes related to paying for drugs when he was unemployed. These are dealt with through the onsite Health Justice Partnership, for whom a non-custodial sentence is relatively easily achieved with reports from several members of Damien’s support team, and commitment to ongoing treatment (psychological counselling monthly suffices to meet that requirement).

IN SUMMARY

At a time when things were going downhill for Damien, when things could have descended into incarceration, alienation from family, worsening mental health, social isolation and self-harm, the downward slide was arrested by a highly skilled, multi-disciplinary approach to stabilisation. The support team around Damien grew and changed strategically as Damien’s needs and the team’s understanding of those needs changed. Damien was continually at the heart of the decision-making process, personally attending several case conferences and always informed of their outcome.

From the moment he set foot in the Centre Damien began to experience incremental, whole-of-life improvements. This commenced with improvements in social inclusion from the warm welcome provided by Lenny, Fatima and the reception staff, and continued through medical, psychological therapy and psycho-social/wellbeing interventions. Much of this support was provided wholly within the Centre where the ability to manage complex comorbidity was essential, as well as maintaining a broad clinical and non-clinical (whole person) perspective. Where specialist support was required from the AOD sector (inpatient detox, AOD support groups and secondary consultation) this was provided with little disruption or inconvenience to Damien. That's integration.

Feedback on this hypothetical case study is warmly welcomed. Please make comments and suggestions however brief or lengthy.

Patrick Lawrence Chief Executive Officer

If you only have one minute, skip my intro to this newsletter and go straight to the ResetLife testimonial below. You’ll never read anything more compelling from us.

As the spread of COVID-19 worsens in Victoria and lockdown continues, we are all tired and over it. Through good management and good fortune, First Step avoided the swathe of tier 1 sites and closures all around us in St Kilda.

The mental health sector is stretched supporting people who were struggling before the pandemic and whose health has worsened, as well as people who were doing okay previously, but are now struggling. Of course we continue to support all those individuals, and double down on our efforts to look after ourselves and our families.

We hang in there and plan for the future.

We have had high level input into the Mental Health Act, the reform of which is being treated as a prerequisite to implementing the recommendations of the Royal Commission into Victoria’s Mental Health System. And from my role on the Alcohol and Other Drug Expert Advisory Group, I continue to emphasise the kind of client journey that we want to facilitate in the new system. One of compassion, welcome, understanding, receiving all the support that is required, engaging family, and care for as long as it’s needed.

We continue to see clients from the clinic, caring for their medical and mental health, addiction management, nursing, and COVID-19 vaccinations. Much of our legal and group therapy work is delivered online, by phone or in a hybrid format. Thanks heavens we have those resources.

We know we will be living with this pandemic for some time to come, but we look forward to higher vaccination rates and the end of lockdown. And when that comes, we will make the most of that well-earned freedom to fight for the best possible outcomes for the people we both care for and are continually inspired by. And as you will read below, there is always reason to hope.

Patrick Lawrence Chief Executive Officer

ResetLife goes online

I joined the ResetLife programme straight out of yet another detox. 

To be completely honest, I didn't have much hope for the programme. I just thought it would give me a few weeks extra of being clean and being able to fix up the mess I had once again caused through my addictions.

That was generally the pattern and had been so for many years. I had lost everything, but most significantly I had lost hope and any belief that my life could ever be anything but a torment. I hated the world, the struggle, people and myself, and simply didn't care anymore. My existence was just that, I wasn't living - I simply didn't know how to.

I was sick of being told that this would help; or that "I should do this", or "you should just stop". I was different and, having struggled with this way of thinking all my life, thought I knew best about my life - whatever that was. I was convinced that no one could understand my problems as they simply hadn't experienced or suffered through what I had. I honestly was not looking forward to another "re-education" from know-it-all group facilitators and self-obsessed peers with their own tales of sorrow and relentless war-stories.

Thankfully, I was completely wrong. The programme has taught me so much from both a spiritual and scientific perspective. The facilitators understood where I was coming from and helped me to regain control of the negative thinking and behaviours that had dominated my life. I learnt so much, it is impossible to put into words. Certainly impossible in a short testimonial. 

The programme has reshaped absolutely every aspect of my life. It has given me structure, belief, new perspective and a humble confidence that I have never enjoyed. I am a new person. It has allowed me to take the time to find out who I am and what underlies my personality and thinking. Further to that it has given me the knowledge and the tools to fundamentally affect what I do with my life. My new thoughts and behaviours are not scary. My thinking isn't confusing. The future is not ominous and bleak. Thanks to all the facilitators, peers and the programme, I understand myself; what I need; what I want; and, most importantly, how to achieve it. I am no longer full of fear and anger. I have belief and confidence in myself. The programme has given me that.

I have hope. I am sober. I am happy. I have a life.  And it is just starting.

Thank you.

ResetLife client

I always related to the symbolism of the metamorphosis from caterpillar to butterfly and the potential for radical and extreme change within oneself – ResetLife Client

The Road Home Project

“The Board of The Ian Potter Foundation was very impressed with the vision of this project and the strong partnership with the homeless services.” – Alberto Furlan, The Ian Potter Foundation

We are excited to announce our new partnership with Launch Housing to deliver health and legal services from within their crisis accommodation sites, in a proof of concept project called The Road Home.

There are six critical support elements that together form the best-practice model for delivery of mental health and addiction care at one site: addiction treatment, mental health treatment, legal support, social inclusion support, meaningful engagement and housing.

First Step provides all but housing because we acknowledge that the provision of housing services differs significantly from the other elements, and that many of our local community partners are already doing exceptional work.

Kicking off in mid-October at Launch Housing East St Kilda, the Road Home Project will bring a First Step GP, mental health nurse and lawyer directly into crisis housing for a weekly clinic.

Over the two years of this project, we anticipate:

• Approximately 100 highly vulnerable people each year experiencing a circuit breaker in the rotating door of crisis accommodation, moving away from crisis and illness and into stability.
• Healthier clients with improved physical and mental health and control over drug/substance use.
• Happier clients with increased motivation to participate in socio-economic life, better able to manage their own medical, legal and housing needs, having trusting relationships with medical and legal staff, developing life, parenting and employment skills and growing support networks.
• A long-term reduction in the number of hospital admissions, interactions with the criminal justice system, and further reliance on the housing sector, which will in turn reduce waiting lists for emergency accommodation.
• A wide appreciation for the new model and a desire to replicate or emulate this model more broadly.
  
  This project has been made possible by the philanthropic support of The Ian Potter Foundation, The Jack Brockhoff Foundation, The Marian & E.H. Flack Trust, The Helen Macpherson Smith Trust, and the Spencer Gibson Foundation.

Long-Acting Injectable Buprenorphine - unexpected results that changed my mind

I first became aware of the Long-Acting Injectable Buprenorphine (LAIB) six years ago at The Australasian Professional Society on Alcohol and Other Drugs conference.

I clearly remember thinking, as Professor Nick Lintzeris spoke, what an incredible game changer this could be for the clients at First Step on the pharmacotherapy program, particularly those on stable suboxone (buprenorphine). I was then super disappointed to hear that it had not even begun a trial phase.

Fast forward a few years, and I heard murmurings that the LAIB had passed trials and was being rolled out into the community treatment space. Despite its availability, I, and several of my clients, felt hesitant about something that had only been proven ‘on paper’.

For many clients who had been on pharmacotherapy programs for a long time it presented an enormous decision. On one hand, attending a pharmacy daily or weekly posed a significant risk – they might bump into someone they know, what if they missed a dose, what if they were judged by the pharmacist? On the other hand, moving to a 28 day cycle was intimidating in itself – attending the pharmacy is an important link to their community, and sometimes, the pharmacist might be the most regular human contact some clients have.

We began small by providing it to people initiated elsewhere, or clients who specifically requested it. It was at this point that I met Stacey (not her real name), the patient whose story significantly shifted my opinion of this treatment option.

Stacey is a 59 year-old woman who started using opiates in her mid-teens and had been on the methadone program for more than 20 years. Throughout this time, she had continued to use heroin and it had continued to cause issues in her life. In June 2020, Stacey admitted herself into a residential withdrawal unit to transfer from methadone to the LAIB program, and we picked up the management of this after she left.

When I first met her, she was demanding, unreasonable and difficult to engage with because of her brittle manner. Our time together over the first three months largely consisted of her telling me what was wrong, and what she wanted me to do to fix it.

Then something shifted. Slowly, and quite subtly, at first.

One of the things we speak about at First Step is the idea of ‘incremental whole –of-life improvements’, and this description perfectly described my interactions with Stacey. On paper, she had only had a slight shift – she had remained on pharmacotherapy, albeit a different type and delivery system. But the effect of this in her life was profound.

The first significant change we noticed was attitude. Stacey was more patient, understanding and could recognise situations around her that were affecting more than herself. She was more polite dealing with people, and the staff recognised this.

From there things just seemed to ‘incrementally improve’. Stacey started to dress differently, as she described, “more appropriate for my age”. And she began planning, weeks and months ahead for things, something she had previously been unable to do.

Over the next couple of months, Stacey would excitedly attend appointments, telling me with an enthusiasm I didn’t believe she had, that she was studying for her Learners, with the view of getting her license for the first time.

It is important to note, LAIB is not a ‘miracle cure’. Stacey committed a tremendous amount of hard work to achieve everything that she did. A clever psychiatrist once told me, ‘pills don’t teach skills, but they give the brain a chance to learn them’, and this was never clearer than with Stacey.

It was a humbling experience watching an adult woman’s life change slowly before my eyes, watching her discover new things she had not thought herself capable of previously.

Haydn Salomons Clinical Care Coordinator

Health Justice Partnerships

The last quarter has been a time of significant growth and expansion at First Step Legal, despite the constraints of lockdown.

After months of service design and planning, we have proudly commenced two new health justice partnerships: one with the Star Health family violence program, and the other with Alfred Health’s St Kilda Road Clinic.

The Star Health family violence program delivers men’s behavioural change groups supported by family safety contact workers and family violence counselling for affected family members and specialist support services for affected children. We were impressed with the client-centred model adopted by Star Health and its integrated, holistic approach to working with perpetrators and victim survivors to achieve long term behaviour change. In May 2021, our family lawyer, Tom Mainwaring, started working one day per week from the Star Health service in South Melbourne, with regular visits to other locations as client needs demanded.

The St Kilda Road Clinic provides outpatient, community mental health services via five differentiated case management teams. It also operates the Homeless Outreach Psychiatric Service, the Mobile Support Team and the Brief Service Response. While some specialist legal services target mental health inpatients, the legal needs of community mental health outpatients are chronically underserviced. In July 2021, our criminal law and generalist lawyer, Elizabeth Frampton, began operating from the St Kilda Road Clinic for two half days per week.

As always, our approach has been to embed legal help in collaborative case management practices that address the underlying drivers of our clients’ contact with the justice system. Already, we have assisted over forty clients whose legal needs may otherwise have gone unmet, assisting them to navigate the legal process and privileging their voices and perspectives along the way.

Integral to the stability of each new partnership is a set of formal protocols and an overarching operating agreement. Each is governed by a Steering Committee, with representation from consumers and senior management of the partner organisations.

These new partnerships are a welcome addition to our longstanding collaboration the Windana Therapeutic Community at Maryknoll, enabling us to reach a greater number of clients in a wider range of settings.

Tania Wolff Accredited Specialist in Criminal Law Director of First Step Legal

4 August 2021

You might not think about them every day except for when you are brushing them, but your teeth are really, really important.

Those of us who have suffered through serious dental issues know the pain, the anxiety, the expense and the further health implications. We all need to understand that our mouths are the gateway to our insides, the primary physical interface between the world and your internal body. So integrated is the human body, and so important is the mouth and what’s in it, that tooth and gum disease can even lead to infections in your heart and brain.

Complicating matters is the fact that our teeth haven’t evolved to last 80 or 90 years (more like 40). That’s something that doesn’t happen without intervention.
And what about your smile? Now that’s something you probably take for granted. How critical is it to your self-esteem, your ability to calm, influence and even lead others? A smile is so powerful that even if you fake one you can’t help feeling a little happier - try it!

What if your teeth were significantly decayed, broken, discoloured or missing, enough so that smiling was eliminated from your repertoire of self-expression? That’s devastating for mental and general wellbeing.

This is the case for many people on opiate substitution therapies such as methadone. Not only is there a close association with poverty and homelessness, but methadone (like other opioids) can cause dry mouth which hastens decay. A great many of our clients at First Step, for reasons of childhood poverty, grew up without access to adequate, modern dentistry and have received insufficient dental care. The same goes for children who suffered neglect and abuse, for early-school leavers, for people suffering from addiction, for people who are chronically unemployed or underemployed.

But wait, there’s public dentistry.

Yes, but ‘wait’ is the operative word.

Wait times for public dentistry can approach 3 years, that’s right, 3 years, particularly in rural and regional areas. How motivated would you be to seek the help you need today if you knew it wouldn’t come for 25-30 months, and that might include a fair bit of shame and pain?

Investing in public dentistry is an attempt to redress the historical inability of the health system to look after all its constituents. It’s about human rights, about equity, about dignity, and about what’s right.

At First Step we urge state and federal Departments of Health, and their responsible Ministers and departments, to prioritise increased investment in the availability and quality of public dentistry.

And for those involved, bravo to you! Please continue to treat vulnerable Victorians with the dignity they deserve and keep informed about the trauma people have suffered relating to their whole selves, but particularly to their mouths and to their teeth.

As with so many public health investments 1) it will alleviate pain and suffering, 2) we cannot afford not to invest more, and 3) it’s the right thing to do!

Patrick Lawrence Chief Executive Officer

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

Patrick Lawrence Chief Executive Officer

Although the tight lockdown has eased in Victoria, we are still navigating restrictions that mean we can’t connect with our family, friends and community the way we would like to. But now, more than ever, it’s important that we do connect.

It’s Men’s Health Week and the focus this year is on what it means to have a team, to stay connected and seek support early if something is wrong.

Aussie men make up the majority of premature deaths, have a lower life expectancy, a higher rate of suicide, and double the rate of heart disease, than women. There are a complex range of social and behavioural factors and barriers that influence this, which Dr Niall Quiery explores in his article, “Who’s on your team?”

Do you remember our International Harm Reduction Day Appeal? With your support we raised an impressive $49,340! This crucial funding means we can be there for people when they need us, to keep them safe, engaged and empowered to make better health choices.

We absolutely rely on the support of our community to do the work we do, to be the safe place people come to in their recovery journey. For some, it’s their only place.

We need your help to make sure we can keep connected, keep being a beacon of hope, and keep being the safe place for the 2,000 clients we see each year. As we approach the end of financial year, please consider making your tax deductible donation to First Step.

Patrick Lawrence Chief Executive Officer

Who's on your team?

Did you know that the life expectancy for men is 4 years less than for women?

It is no surprise when you consider some of these facts:

•   Men are 32% less likely to visit a health professional
•   Men are less likely to seek therapy if they are feeling down, or anxious
•   Men experience higher rates of suicide and motor vehicle accidents
•   Men are more likely to drink excessively and smoke
•   Men are more prone to serious health conditions, such as heart attacks and diabetes

To turn this around, we need to understand why men don’t look after their health enough.

1. In many cultures, concepts about masculinity often make men feel pressured by societal expectations to appear strong, self-reliant and emotionally guarded.
2. Men take, and tolerate, more risks than women, so they present to the doctor later in the course of an illness.
3. Many men in their 30s stop exercising regularly, or participating in club sports, and instead become spectators. And in Australia, alcohol is frequently embedded in sports culture.
4. Men and women engage differently. Research has shown that women will volunteer information to a doctor, whereas men have to be asked.
5. Men often require prompting from a partner or friend to seek medical support.

At First Step, we dedicate a lot of time to forming relationships with each man. It’s a little bit like fishing – we put out a line and slowly reel them in, over time engaging at a deeper level!

We work hard to create a place where men feel comfortable and feel good that they came. We support them to set short, medium and long term goals that they want for themselves, that they can achieve incrementally. We address diet, exercise, self-esteem and healthy lifestyle choices. We support them – we accompany them.

We understand that the experiences of men differ to those of women, so we focus on engaging them in a different way. We encourage them to value their health so that they can live a fuller life, whether that be work, hobbies or meaningful connections with family and friends. And we encourage men to prioritise their health by staying connected and seeking support early if something is wrong, from a team of people who care about their wellbeing.

So, who’s on that team?

Obviously, we are. We help look after their physical and mental health and connect them to psycho-social services. But many of our clients have other people in their lives who want to see them get better. Trusted friends or family members to stay socially connected with. Teammates they can stay physically active with, colleagues they can eat healthy lunches with, or other people they meet along the journey.

This year, Men’s Health Week focuses on what it means to have a team. Who’s on your team?

Dr Niall Queiry General Practitioner First Step

It's never too late to change direction

The first time I drank to black out, I was 14.

By then, I was already bulimic.

As the only child of an emotionally distant single mother who failed to protect me from the men in her life, it was the only way I knew how to lock up the feelings and experiences that were happening to me.

I could not wait to escape home at 18 but was not prepared for life on my own. I found myself working night shifts in hospitality, using drugs to keep me awake, and drinking to black out.

I had no idea who I was. Each crowd I fell in with, I moulded and adapted myself to them, searching for acceptance and love. But inside, the anxiety would torment me, and I would muzzle it with alcohol and drugs.

Until I found out I was pregnant, and not long after, delivered my son at 26 weeks. This was a time of extreme stress and strain, but I managed myself without taking drugs or drinking, and I felt proud.

But it was not long until I relapsed.

In 2013, I met my husband. This was the first healthy, functional relationship I had ever had. I felt loved. But I also felt that I did not deserve it.

At the age of 43, I unexpectedly fell pregnant with twins. The pregnancy was complicated, and I delivered my girls at 29 weeks. This time, I did not cope and began drinking regularly.

I felt isolated and alone. My children were quite boisterous and difficult to manage, so we rarely went out. Every day was Groundhog Day and to escape this, my drinking escalated. I was self-medicating to cope.

Over the next two years, I accumulated a significant credit card debt which was primarily all spent on alcohol. Then the Department of Health stepped in, and I feared that I would lose my children.

I started to seek help – I went to AA meetings, spent 3.5 months in a rehabilitation facility and three stints in detox. But each time I would relapse. I couldn’t understand – I did everything they asked me to do. What was wrong with me? Why wasn’t it working?

Meanwhile, I was spiraling out of control. My husband was supportive, but did not know how to help me, or protect himself and the children. On one occasion I was admitted to emergency because I was suicidal, on another, with alcohol blood levels so high I was at risk of going into a coma.

I didn’t know what to do, but I was sure I could not return to residential rehab. I couldn’t quit my new job – it was stimulating me and allowing me to financially contribute to the family. And I couldn’t bear to be without my children for another 3.5 months. But I was putting them at risk, and I was going to lose my husband.

Then I found ResetLife at First Step.

ResetLife is a day program that allowed me to continue working and being with my children. It was the answer I was looking for.

Up until this point, I felt like I was carrying around an empty toolbox. ResetLife filled it up with tools that I could use in daily life. And I learnt that alcoholism is a disease that does not make logical or rational decisions.

If I had not learnt this, had not filled my toolbox, I would still be in the cycle of relapse.

Now when I am faced with challenges, I allow myself to feel emotions, to experience what is happening to me, with the knowledge that I know how to manage them, to move through them, and to implement practical steps. I use the tools that I learnt at ResetLife.

I want to be totally present and available for my children. To be the mother I wished I had. I want them to grow into happy, healthy, secure adults who make wise decisions. Who know that it’s never too late to change the direction their life is taking.

ResetLife educated me. That was this missing piece. It provided support to me and my husband and showed me that I can live a life of abstinence. I was able to make meaningful connections in a safe space whilst staying at home with my children and in my job. Now I have inner peace, gratitude and hope for the future. Hope that I can break the generational cycle of addiction. And hope that my family and I can lead full, happy and healthy lives.

This disease will not bring me down.

To protect my privacy, Emma is not my real name. But this is a picture my 5 year old daughter drew of our family.

People recover in the context of relationships

“People recover in the context of relationships” - we’ve all experienced this. When we go to the doctor, we don’t just want someone who knows how to use a stethoscope, we want a human being, preferably one who knows us well and cares about us.

This need is especially acute in people with complex mental health needs who have so often been disappointed by authority figures and ‘the system.’ During a consultation, the individual needs to know that they matter, and nothing says that better than a health professional that is there for the long haul, with no threat of a future cut-off date.

The mental health system is highly focussed on ‘episodes of care’ (if you’ve never heard that term then you’re lucky), at the end of which a person might be stepped up or stepped down, to another provider, in another organisation, or no provider at all.

However, we know full well that recovery from mental ill-health is non-linear. Good days and bad days, good months and bad months. The idea that someone should be constantly transitioning in, and then being pressured to transition out of care goes against what it means to have a healthy community.

At First Step, as much as is humanly possible, we maintain long-term, years-long therapeutic relationships with clients. There may be periods of high acuity (frequent support from a multi-disciplinary team) and periods of little or no contact.

Of course, we want people to recover and no longer need our services but wishing doesn’t make it so. We are concerned that some areas identified for considerable (federal) government spending such as the Adult Mental Health Hubs ($400M+) will only provide short or medium-term support, which will exclude complex clients and people with histories of trauma. It’s not good enough.

In the meantime, we’ll do what we do and try to make a fair bit of noise about it to inspire others and inform government models.

Towards reform: looking at how to provide effective care

We are proud to announce that First Step has been appointed as lead agency for the Victorian Department of Health Integrated Care Capability Pilot. This pilot will test the implementation of a Comprehensive Continuous Integrated System of Care (CCISC) across 10 organisations in greater Melbourne.

What are the implications of this?

For us at First Step, it means progress. Perhaps even better, it means hope.

That might sound dramatic, but for the 100,000+ people in Victoria each year that desperately seek treatment for complex mental health and addiction issues, this pilot is the first small step towards reform and improvement, in a system that has long struggled to provide effective care. The pilot extensively references findings from the recent Royal Commission into Victoria’s Mental Health System in its design – a very welcome sign of change.

The CCISC Pilot provides a framework with which to examine what happens each time our organisation(s) come in contact with a client, and then explores ways to improve each of those interactions. It draw’s deeply on the experience of people that currently use, or have used, ‘the system’.

That’s exciting because it means we have a better chance of providing services that truly meet the needs of people in our care. Services that foster a sense of hope for the future, and then actually deliver.

It is a collaboration of 10 organisations who will individually and collectively work through the challenges of this process, supported by the Department of Health and several significant industry experts. It represents an opportunity to streamline the way our services communicate with each other, reducing the risk of people ‘falling through the gaps’. If done right, it represents an immense opportunity to leverage the expertise of each other for our own organisational growth, specifically for the benefit of the people in our care.

This is a principle that we employ at First Step every moment of every day. We know how powerful it is when you get committed people collaborating on a challenging issue. Good things happen. Are we excited by the chance to employ that at an organisational level? Absolutely!

The very nature of a pilot is exploratory, and this one is no different. The pilot will commence in earnest in the coming weeks. There is much to learn and so we are gearing up.

For our clients, change can’t come soon enough.

6 May 2021

Niels Bohr said the thing about great truths is that the opposite is also true. Isn't that the very definition of counter-intuitive and fantastically thought provoking because of that? Below I lay out a great truth about mental health, and then sort of its opposite. We have to hold these twin truths (or something like them) in our minds if we want to overcome stigma and make best use of this incredible reform opportunity in mental health that sits before us (post Royal Commission into Victoria's Mental Health System).

Truth #1: The combination of mental ill-health and substance use (alcohol or other drugs) can happen to just about anyone.

You, me, your parents, your friends. It is really important that as a society we get our heads around this. Just like with physical health, we are seldom in perfect nick and we have our ups and downs. Just like with physical health, sometimes it’s serious enough to require professional intervention. Even those who don't drink or take drugs in today's insane world are at risk of addictions, perhaps to work, or sex or screens.

All of us. Any of us.

Truth #2: Chronic substance use and mental illness are concentrated in areas of great disadvantage and poverty.

It’s kind of obvious that absolute poverty is a cause of ill-health – think perhaps of a developing country with insufficient food supply. But relative poverty (being poorer than those around you, suffering the disadvantage and stigma) is also a source of ill-health. Australia is growing ever more unequal, and poverty is the ‘cause of the causes’ of chronic mental ill-health.

We all experience pain and loss as children and adults. However, we need to appreciate that there is a tangible difference in expected life outcomes between those of us who had a relatively stable upbringing (often characterised by having at least one constant, caring parent) and those who did not. This is about acknowledging that there are things we all need, the absence of which creates vulnerability, sows the seeds of neglect and abuse and leaves trauma in its wake.

Connection vs isolation. Support vs neglect. Financial resources vs poverty. Encouragement vs silence. Love vs nothing. Any human being sliding to the right on some of those scales will need to summon extraordinary resilience and ingenuity just to survive.

What do we do with this information? We apply our compassionate minds to the project of understanding. We need to see our own vulnerability as we imagine the child that lacks what we all know are essential elements for the daily experience of happiness. See our own vulnerability and remember our own struggles as we imagine the teenager who never had anything close to the basics (and I don't mean material possessions). Picture the young person who made it to 18 years of age without once being told or showed that they were loved, perhaps recently moved to their 30th group home or foster family. The likelihood of early school leaving, pre-teen alcohol and drug use, periods of homelessness and interaction with the law are exponentially more likely for any human being suffering ‘adverse childhood events.’ And the adult? Yes, I think we'd better maintain our compassion for them too.

So, what do we do about this injustice, this inequality, this suffering? We look after ourselves and our own mental health, we look after our friends and family, and we seek to contribute in some way to a society where people get all the help they need. Mental health. Addiction. Cancer. The approach should be the same. Integrated, state of the art support to alleviate pain and suffering, and quite possibly save a life. Delivered wherever possible from one team in one place. To do less is unacceptable.

And what is the fundamental difference between cancer and addiction or mental illness? Simply stigma.

Do we deny cancer care to my aunty Lorna who smoked her whole adult life? Do we write-off her illness as self-inflicted and her care as doomed to fail? Hell no! We fight the good fight. We allocate resources, we build the Peter McCallum Cancer Centre, we research, we give a damn. We reduce harm as a matter of principle. Let’s get over the stigma and do a bit more of that in the field of addiction. Mental health is responsible for 20% of Australia's burden of disease and receives (historically) about 7.5% of health funding.

We are in a period of extraordinary reform in the mental health sector. Don't let addiction be an afterthought.

First Step is running an awareness and stigma busting campaign for International Harm Reduction Day (May 7th). Please click here to see the amazing video contributions of government ministers, workers, doctors, magistrates, campaigners and others: https://www.facebook.com/TheFirstStepProgram

And to contribute to First Step's fundraising campaign: https://first-step-program.giveeasy.org/international-harm-reduction-day-appeal

Patrick Lawrence Chief Executive Officer