From 'Passing the Buck' to Integrated Care

Co-occurring Mental Health and Substance Use Crisis

In February 2019, after years of pressure from people living with mental illness or psychological distress, families, carers, and health care professionals, the Victorian government established a Royal Commission into the mental health sector.

The commission found that Victoria’s mental health system had “catastrophically failed to live up to expectations.” Over 3,000 submissions were made, the majority by overwhelmed family members who felt they had been left alone to care for afflicted loved ones.

“In the years preceding that day, my family and I tried everything we could think of to get Anna help for her escalating mental health and substance use issues. But despite a clear pattern of severe mental illness, psychosis, uncontrolled substance use, self-harm, and violence, we couldn’t find a single service to provide Anna with the comprehensive residential care she desperately needed.

She was ‘too addicted’ for the mental health services and ‘too mentally ill’ for the alcohol and drug services. Now, a man is tragically dead, and my daughter is in the only publicly funded long-term residential mental health facility in Victoria: prison.”

My family’s submission was one of hundreds to call out the health system for failing people with co-occurring mental health and substance use issues. Families spoke of stigmatising attitudes, disorganisation and lack of communication between the mental health and alcohol and other drug (AOD) sectors, and of being turned away from each sector due to the presence of symptoms managed by the other. They told stories of loved ones who had slipped through the cracks, many of whom were yet to recover, or had already been lost. Victoria isn’t the only state to be plagued by these issues: lack of integrated, respectful crisis care for people with co-occurring needs is an Australia-wide problem.

According to Robert Stirling, CEO of the Network of Alcohol and other Drugs Agencies (NADA) in New South Wales, the problems start with a workforce culture of stigma towards people who use drugs. “In hospitals in particular, there can be an attitude that people who use drugs are less deserving of crisis care, due to perceptions that they ‘did this to themselves’, or that their problems are ‘all just caused by the drugs’.”

Frankie (not her real name), a Sydneysider who spent years trying to get help for a combination of depression, anxiety, and problematic use of methamphetamine, was on the receiving end of the culture of stigma. “When you’re already thinking about killing yourself, and you’re there because you’re desperate for support, being shamed and blamed is enough to tip some people over the edge,” she says. “They tell you to be honest and disclose your drug use, but when you do, they judge you and turn you away.”

“My observation is that people learn not to disclose their drug use to health services,” explains Will Tregoning, founder of Sydney’s UnHarm, a non-profit seeking to challenge stigmatising assumptions about drug use by mentoring people who use drugs to ‘come out’ and share their stories publicly. “They have perfectly reasonable fears of being discriminated against and misunderstood.”

Frankie, who was media trained through UnHarm’s mentoring program, continues: “The nurses and doctors at hospitals have this attitude that people who use drugs are dishonest because of their addictions, but we have no other choice if we want a chance at accessing care. We don’t want to lie – we are forced to.” As Will adds, “People who use drugs need to feel they can disclose their history without potential adverse impacts on their care.”

Patrick Lawrence is the CEO of St Kilda’s First Step, one of the few services in Victoria designed to serve people with co-occurring needs. “The system was built on the assumption that there is little overlap between people with substance use issues and those with mental health issues. In reality, these problems go hand in hand the vast majority of the time.” The result is a system notorious for buck-passing. “We hear all the time about people who have fronted up to hospital in acute crisis and been told that they need to ‘deal with the drug issue first’. They are handed a pamphlet for a rehab and sent away.”

But, as Frankie learned, accessing rehab can be just as tough: “I was told by people in mental health that I needed to get ‘clean’ before they’d treat me. I managed to get into a detox facility and while I was there I spent all day, everyday, calling rehabs – most told me they weren’t qualified to take on someone with mental health needs, or they were way too expensive, or they had years-long waiting lists. I was lucky to finally find somewhere that was willing to take the fee straight from my Centrelink payment.”

My sister had no such luck. “After finally reaching the top of the waiting list for Victoria’s PARKS mental health program, Anna was expelled on the first day,” Mary explained at the Royal Commission hearings. “She had stashed backups of her prescribed medication in her clothes because she was afraid that she wouldn’t be given enough meds to subdue her withdrawals. The staff told her she’d broken a rule, and she was kicked out…. No one would take Anna on.”

Currently, hospital psychiatric wards are the only large- scale services equipped to take on people with co-occurring needs who are at crisis point. After years of being turned away from services, my sister’s untreated schizo-affective disorder, uncontrolled drug use, and resulting psychosis finally landed her on an involuntary hold at a psych ward.

My family was elated. It never occurred to us that Anna would be discharged – we assumed that once the severity of her issues had been recognised by health staff, it would be incumbent upon them to ensure she was looked after. But we were wrong. “The hospital discharged my daughter into the care of man twice her age who had worked as her driver in his capacity as a volunteer for a local respite organisation.” said Mary. “We couldn’t believe the psychiatric staff hadn’t taken into account Anna’s lack of capacity to give informed consent, the age of the man, or the ethics of him showing a romantic interest in a mentally ill person he’d worked with.”

The next time Anna was discharged from an involuntary hold, she begged the psych nurses to let her stay. “She didn’t trust herself,” Mary continued. “She didn’t feel in control of this demon inside her that wanted to hurt her and the people around her.” The nurse on duty told Anna “This isn’t a hotel”, and she was sent to a boarding house where people were fighting and using meth.

Gillian Clark, project worker for the mental health royal commission at the Victorian Alcohol and Drug Association, observes that “The psych wards are so short on staff and beds that they can only take people on for a few days, then they are discharged back to the situation they came from – or sometimes worse.”

With so many complex problems, Victoria’s Royal Commissionoffered a rare glimmer of hope for the possibility of workable solutions for the mental health and AOD sectors and a potential model for other states. The Victorian government accepted all of the commission’s 65 recommendations, including one that specifically urged integrated care and non-exclusion from treatment for people with co-occurring mental health and substance use issues.

The state Department of Health is currently in the process of translating the recommendation into actionable guidance for the AOD and mental health sectors. But in the meantime, complex problems remain unaddressed. Again and again, people I spoke to identified a need for comprehensive anti-stigma training of hospital and mental health workers.“We need to be working to foster a culture of respect for allpatients,” says Patrick.

The conclusion to my sister’s story remains unknown, but for now, she is safe, medicated, fed, and getting a chance to practice the social and self-care skills she had yet to master on the outside. The sad truth is that, in the absence of longterm residential care for people like Anna with complex or co-occurring needs, prisons will continue to function as de facto mental health wards. There is nothing that we can do now to take back the awful thing my sister did. And despite the lack of support in the preceding years, Anna takes responsibility for her crime and feels that her sentence, of 13-17 years, is a fair one.

What we can do is focus on changing things so other people in situations like Anna’s have access to appropriate health care for co-occurring conditions. As Gillian points out,“Health care is not something that should ever be denied.Healthcare is a human right.”