Subscribe
Share
Share
Embed
The Hamilton Centre Podcast | Exploring Mental Health & Addiction is for service providers, individuals and family members dealing with co-occurring mental health and substance use conditions. In response to the recommendation of the Royal Commission into Victoria's Mental Health System (2021), the Centre was established to create a more inclusive and supportive system by promoting integrated care in Victoria, Australia.
Our podcast will feature interviews with service providers, individuals with lived experience, and workers who assist people with co-occurring conditions. We aim to promote holistic care throughout Victoria by breaking down barriers to treatment and through open minds and open doors.
This series features Gemma Turvey's composition, "Turquoise," performed by Gemma on piano, Craig Beard on vibraphone, and the talented musicians of the New Palm Court Orchestra.
Welcome to the Hamilton Centre podcast, a space where we explore the thinking of leaders, service providers, workers and people with living and lived experience shaping the landscape of integrated care in mental health and addiction services in Victoria. I'm Annie Williams, Hamilton Centre relationship and partnership lead and your host today. The Hamilton Centre acknowledges with deep respect all First Nations people and traditional owner groups within Victoria. We extend that respect to the traditional owners of the land on which this episode is recorded, the Wurundjeri Woi Wurrung people of the Kulin nation, and pay our respects to elders past and present and acknowledge their unseated connection to land, sea and sky. Hamilton Centre recognizes people with lived and living experience of mental ill health, alcohol and other drug issues, and of recovery and the experience of people who have been the carers, families or supporters of people with co occurring issues as their experiences help us shape services that are safe, accessible and inclusive.
Annie:I'd like to welcome you to a very special episode as we celebrate the Hamilton Centre's two year anniversary. Today we're diving into some really important topics, everything from stigma and community attitudes to the future of integrated care in Victoria's healthcare system. We'll also explore the key changes, challenges and opportunities in delivering mental health care and addiction care together whilst reflecting on the incredible work our team and clinical network have been driving in this space. For this conversation, I'm joined by two thought leaders in this sector, Professor Margaret Hamilton AO and Associate Professor Shalini Arunogiri, who has been at the forefront of this work for many years. Professor Margaret Hamilton has over fifty years of experience in the alcohol and drug field.
Annie:With a background in social work and public health, she's worked across a wide range of research, including clinical and population epidemiology and policy. She's held impactful roles as executive member of the Australian National Council on Drugs, President of the Cancer Council of Victoria, Board member of Vic Health, and was the patron of Dana, the drug and alcohol nurses of Australasia, and is a life governor of the Australian Drug Foundation. Until recently, Professor Hamilton was the community member on the Mental Health Tribunal and last but not least, the founding director of Turning Point Alcohol and Drug Centre in Victoria. Associate Professor Shalini Arunogiri is the clinical director at both Hamilton Centre and Turning Point, and a clinical researcher at Monash University. Her research focuses on co occurring mental ill health and addiction.
Annie:As an educator, Shalini is passionate about inspiring the next generation of medical professionals and actively promotes addiction psychiatry as a career to the medical students and junior doctors she mentors. It is a pleasure to have you both here. Thank you so much for joining me today.
Margaret:Thank you, Annie.
Shalini:Thank you so much, Annie.
Annie:So, Margaret, I'd like to begin, if I may, talking about integrated care and the importance of integrated care, both at the personal level but also the systems level. And I'd be very interested to hear your thoughts on this.
Margaret:Well, I guess that very early on in my career, I had an opportunity to work in what was then casualty at St. V's. And I noticed that people coming in presented whatever problem they thought you, as the person they encountered, would respond to. So I figured that they didn't come in just because they had a physical problem. They didn't come in just because they were homeless.
Margaret:They didn't come in and say, I'm drunk, and I I don't know what I'm doing. They didn't come in and say, I've just had enough. They came in, and if it was the nun they saw, and that's who was at the front desk in my early time
Margaret:They would give some religious sort of connectedness. When they saw the nurse, they would say: Can you get me some medication or medicine? Can you fix up this sore on my leg? When they saw the doctor, they would say, oh, doctor, I'm in pain. I can't you know, it's just so bad, and I really need some. And if they saw the social worker, they'd usually start by saying, I've got nowhere to sleep tonight, love.
Margaret:And so I realized very early on that one of the things is people present what they think will evoke what they want. But the service systems are not very good at discerning what they want at that time. And so I've always been very tuned in to trying to enter the world of the service user or consumer and understand, work hard to understand what is it that they want.
Annie:The multifactorial.
Margaret:Yeah. Because if you don't have that, you might give them, you might have dressed the wound, and out they go to sleep rough overnight. You know, and so on. So I think integrated care is essential at the personal level for people to feel that somebody is actually trying to attend to what they want at that time.
Annie:Mhmm.
Margaret:They mightn't want it tomorrow or yesterday, but that's what they want, and in that sense, that's what they need right now.
Annie:In the now. Yeah.
Shalini:And that's I think drawing on that, I might share a story that kind of looks at mental health and addiction in that lens as well, I think, in terms of integrated care. Because I think, often we get the opportunity to work with people for very short periods of time. And sometimes when we have the privilege of actually getting to know someone over a longer period, we get to see, I think, that spectrum of needs that you were touching on and and then the capacity to be able to work with someone, and often, you know, interchangeably across that time. One of the things that I've had a real pleasure of being able to drive in my career is around a clinic that we set up to look at trauma focused therapy for people who have thought trauma and addiction. And that came out of, you know, not really having a lot of services to to offer to people.
Shalini:But one of the things that we really learned, I think, from running that service, learned from the people that we're working with, is that for a lot of people, they were kinda coming in saying this is kind of the root of what I'm struggling with here. And lots of treatments that treatment settings, places that I've been to, been able to kind of touch on different parts of the problem. But not necessarily kind of get to the nudge of what was driving a lot of things for people. And so part of integrated care, really offers that opportunity of being able to see the spectrum of need, see the different things that people are struggling with, but also be able to work with all of it rather than necessarily just one part of it.
Shalini:And, you know, in experiences where we're able to do that, I think it can be actually really rewarding for clinicians as well, because you're actually being able to see people being able to kind of move on with life, being able to engage in recovery or with families and their pets and doing things that they weren't otherwise able to do.
Margaret:Yeah. And I think that issue of time and focus is really important and quite problematic in particularly in the mental health system that we currently have. And it reminds me very much of an early student experience when I worked for some time in youth probation and parole. And I remember walking into an office and someone saying, there's your caseload. They're in all those files.
Margaret:And I said, well, how many are there? And they said, oh, there's probably three to 400. And I said, well, how can you work with that number? But it really they didn't have an answer.
Margaret:But I worked out what I would do, and I often suggest this. You're going to be overwhelmed inevitably. Try either once a day or one time in the week to choose somebody who presents as a consumer of whatever service you're in and say, okay, I have to do a quick assessment, quick response to everyone else, but I'm actually going to try really hard to use as much of my knowledge and skill and understanding to get inside what's this person's experience and how might I be able to help them. Because it's the only way as a clinician of feeling any kind of reward and potentially seeing some feedback. But I think in the mental health system, especially, for those frontline clinicians, getting feedback is almost impossible because they often are not there when the person rebounds or they're not there to receive the feedback from the community based service that they're actually doing okay.
Margaret:And the community community service is too busy to send them feedback. I think the time available is very challenging.
Annie:Do you think, though, that if we have a functioning integrated care system that those small things like rewards for the clinicians and feedback would actually become an integral part of the clinician's experience?
Margaret:I would hope so. And I have always tried to emphasise getting back to the source of the information or the source of the referral is vital for you to keep on early research on referral, for example, said that without feedback, referral is not very helpful. And I think, you know, that's back in the fifties, sixties, seventies research. And so having feedback is really vital to close the loop on the clinicians and the patient's experience.
Shalini:I think the other, you know, element to that is also supervision and the capacity to have sort of reflective practice supervision, which I think is a really valuable part of of training in a multidisciplinary environment as well. You can kind of really, you know, even if, as you say, you don't have that opportunity to spend enough time with folks during the day, you've got the space once a week, once a month, even with peers and colleagues, where you're actually taking a step back and thinking, how did we go there? You know, what can I learn from this experience? What can I learn from colleagues? And I think with integrated care provision specifically, I think it allows that space to learn from colleagues that might work from other sectors or different perspectives as well from you.
Shalini:So, you know, if you're working in the drug and alcohol sector, being able to engage with your mental health colleagues and communities of practice as well allows us to take different perspectives on on what we're doing.
Annie:Yeah. And spreads that message of integration across the craft groups. Yeah.
Margaret:And I think that issue of learning from feedback is also relevant on the one to one with consumers of services. Because so often, in alcohol and drugs to some degree and in the mental health arenas, people say, oh, they've tried withdrawal, didn't work. Or they've tried methadine, it didn't work. They've tried buprenorphine, didn't work. Like, I just often think that people who've managed to give up cigarettes, for example, have often had to try many more times than one. So I always say, but what was learned through that? How long did they manage? And what helped them? And what hindered them staying?
Margaret:They made a decision and actually include that in the notes, in the review notes so that next time they come back, we think, okay. So last time they managed three days of whatever, but then something happened. So is it crisis? Is it housing? Is it families?
Margaret:Is it relationship? Etcetera. So I think that learning through experience makes a huge difference. And maybe around alcohol, people start to learn that actually, if I don't drink for a couple of days or more with help to avoid serious withdrawal, this is what I can learn. And without that learning, why would you stop using things that make you feel temporarily better?
Annie:If we think about that curiosity that needs to be applied to each individual's story, Margaret, you've for your whole career, you've championed better treatment and care for people living with addiction and mental health issues. And part of that journey is about changing perceptions and attitudes and the stigma related to addiction in the community. So as Turning Point's founding director in 1995, what was the perception of addiction and co occurring health issues in the community at that time?
Margaret:Well, it's sometimes hard for me to separate out the different eras because one of the things that has characterised these two arenas of assistance or help has been they've had times when they've both been administratively under the same umbrella.
Margaret:And they've had times when they've been completely separated and run by quite different sections of health departments. And usually within health, at least, though there were a lot of services that related to prisons, but they were in a completely different box. So I was pretty aware of that, but I was also aware that we had to start to deal with the harms to the society beyond just the the harms to an individual. And so I also had to manage a locality where our consumers of the service lived or didn't live but hung out or traded or sourced. And that meant managing the various people who lived and the traders in and around Fitzroy.
Annie:Oh, yes.
Margaret:And there was a time of great change. So fairly early on, I thought, I need to go beyond working with the health services, mental health services, so the physical health, the mental health, the welfare services, which included a lot of services for the homeless. I also need to cope with the legal services, with indigenous, the aboriginal health and aboriginal legal service that were. But I also reached out to the police because I thought we're probably gonna need them from time to time. Sure enough, we did.
Margaret:We actually had a really awful incident of a stabbing in the waiting room one day. But I also got to a point where I if there was a lot of drug stuff happening on the street, and that would happen sometimes, gathering, I could ring the local police and had a good relationship. And they would just send a car past, a police car, and they'd just check it. And that would usually dissipate the trading activity. Or we would send out one of our nurses on a bicycle to the watch house to help them manage someone they hid in the watch house. It might have been withdrawing or just not well or causing nuisance. So I always knew that we had to deal with the mix of those things. And I was extremely committed to ensuring that the clinical service was grounded in and helped produce research and evaluation. And to do all of that, we absolutely had to do training and education and begin to train and educate the systems around us.
Annie:I love the story of the nurse on the bicycle. I mean, do you think that by sending people into the community, did that change the attitudes of the workers in the watch house, for example? Or did the police, you know, have different perspectives on the people that were using your services as a result of your engagement.
Margaret:Absolutely. I mean, most of them, I think, came to appreciate.
Annie:Mhmm.
Margaret:Oh, it's quite handy to be able to ring up and say, we've got someone who's run amok. Can someone come down here? And the one who was particularly good at was Mel, and he used to get on the bike, and he would go and sort it. And if they needed medication, he could access people to help with that. If they just needed listening to for twenty minutes, he could do that.
Margaret:He was just very skilled at just quietly and competently doing a quick assessment. And I took that ultimately to much higher systems levels. So in my role on the National Drugs Advisory Council over the years, I worked very easily and well with police commissioners, the AFP Police Commissioner, customs officers, and then for the time that I was working in the UN as a member of the civil society group, I could easily manage conversations across those sectors. So I think some understanding of those different systems and how they operate.
Margaret:As well as understanding how an individual makes meaning out of their life and assist them to make meaning that they value. I think as always worked for me. And it was important with Turning Point.
Annie:Shalini, can I just ask you, do you see those barriers now in your work?
Shalini:Yeah. I think, you know, when you're thinking about sort of mental health and addiction, I guess, we're really talking about two problems that arise amongst a spectrum of kind of vulnerability and disadvantage as you say. There are lots of different kind of sectors that interrelate then. So I think that's still very much a feature.
Shalini:I think I'm not sure that, you know, on a system level where we've progressed dramatically far in terms of being able to get into system system and sectoral working. And it often comes down to those relationships and those openness to having those conversations, I think, to weave that together. But I think, in terms of stigma and perception and attitudes within the community, I think we have come probably quite a way, particularly in regards to, I think, mental illness and how that's perceived. And I think that's down to a lot of that's down to also public awareness and campaigns that have specifically targeted stigma in relation to mental health.
Shalini:And I think, you know, we have commonly shared, for instance, statistics around this now. We know one in five people are affected by mental illness. And we know also that those conversations around, say, depression or or even experiences of suicide, those are are much more acceptable to have those conversations. People are feeling like they can open up and discuss these things with friends, with within their community.
Shalini:So I think that we have seen some shift there, which is rewarding sometimes when you look back and think, nothing's changed. But some things have changed and come a long way. I think when it comes to drug and alcohol use, though, and substance use more broadly, both use and addiction, I think both those things have not necessarily had that same focus, that same drive around moving things to a space where people feel comfortable and sharing. And I think to some extent, we still have very much an individual sort of focus when it comes to developing problems with substances that it's down to the individual rather than necessarily, you know, something that's arisen from a from a health problem. So I think there's still a bit of work that we can do, but a lot of great lessons to to learn, I think, from from mental health stigma.
Shalini:And I think the other lens that we can start to think about is this intersectional kind of barriers for people accessing help. They can come from compounded stigma as well. So stigma not just because of your substance use or your mental health problems, but also your role as a mother or as a parent or as, you know, within a particular ethnicity or cultural group where, you know, you have additional kind of barriers to being able to speak out or to be able to actually get help from a service. So I think when we think about that, you know, when people come in through the door, they've already navigated lots and lots of of hurdles before they've actually come in to seek help.
Shalini:And so I think for us, as as clinicians work, is it's acknowledging that. But I think, certainly across the the center and the network, some of the research that we do and some of the training that we do is is really focused on how do we actually shift that stigma and allow people to be able to to kind of access help in a nonjudgmental way. And to also, you know, help people with self stigma that can be very much part of the equation as well, that people feel like they're deserving of help. Deserving of care.
Annie:Yeah. And do you see the inclusion of the lived experience workforce and peer support workers as an important part in reducing this, as you say, self stigma and community stigma?
Shalini:Absolutely. I think the peer workforce and that addition of that stream into not just the clinical sector, but also, I think really importantly, in sort of service design leadership. Kind of governance processes has has really kind of contributed, I think, to to breaking down some of the assumptions that exist. And I think for many of the Hamilton Centre teams that work across the state and the network, I think what they've really kind of seen is the process of having peer workers within your team not only transforms that engagement with the client that you're actually engaging with, but also with the teams as well, the conversations that can then happen within the clinical review meeting, for instance, even within the team, are opened up in a way and transformed in a way that I think wouldn't have happened prior to the stream actually being part of the workforce.
Annie:So contributing to reflective practice as well.
Margaret:It's interesting to think about peer support because I have, or peer workers and peer involvement, have two points of reaction to that. One is related to my very early career experience, and the other one is the current systemic one. So I'll just talk about the systemic one first. The fact that currently we've got a Victorian government that has agreed to do pill testing but not yet set up a second injecting space of any sort, it's rather sad for me because I think it speaks to the different and the stigma. The stigma of someone who's injecting drugs is regarded as, well, you're an, you know, that's an addict.
Margaret:Whereas young people who are experimenting are seen as vulnerable and needing assistance and advice and information. I agree with that, but I'm rather sad that we can't see these as on a spectrum. However, there's an opportunity there. We've got a community of people, of parents and a community generally, who's quite worried about aspects of young people's drug use, whether it be pills or vaping. You know, there's a whole new generation of older caregivers who are very worried about these things.
Margaret:And I think we've got a real community educational role to get in there and use the worry to help them also understand that there is a spectrum of use and a spectrum of harm. And you can get into a lot of trouble on a single use of a totally single single drug. But you can also get into a lot of trouble with little bits of use over a long time. Indeed. So that's the the systems one.
Margaret:At a personal level, I had a commitment always to self help or what used to be called self help or mutual aid. Because very early in my career, working as the social worker in what had just become the alcoholism clinic, and a real aspect, I suppose, of stigma is when that clinic first started at St Vincent's in 1964. It was called the Special Clinic as a way of trying to avoid the stigma. Oh. And then in the very late sixties, it changed to be called the alcoholism clinic.
Margaret:And all of the sign offs that we had to do was both special clinic slash alcoholism clinic till about 1973 or so, and then it could just be the alcoholism clinic. So it's a signal about that stigma. In about 1970, I went to my first AA meeting because I didn't ever apply for a job in addictions. I applied for a job as a social worker for a new department of community medicine, and that's what I was interested in. At the end of the interview, they said, and what about the alcoholism clinic?
Margaret:I said, well, I don't think I know much about that, but I'll give it a shot. You know, I'm happy to learn. I learned probably as much from the AA members as I ever learned from the clinicians that I then worked with for about six years. And I found them to be enormously helpful, and they taught me all kinds of ways of assisting somebody who was trying to deal with or change their pattern of alcohol use. I also then went on and had the opportunity to do some evaluation research with others, John and others, who he did his PhD ultimately on the research about self help.
Margaret:And he did that through looking at ODYSSEY and the outcomes of ODYSSEY, people who go to ODYSSEY. Others did other aspects of NA and AA. So I've always been very committed to working with people with lived experience because they can teach us a lot. And I'm just really pleased. I think that's one of the very positive changes in terms of integration.
Margaret:It's not without complexity, but it's a very valuable aspect of the more formal part of the care systems now.
Annie:And with that inclusive mindset of including peers and lived experience workers, what key policy changes do you think need to be enacted, really, to support this prioritisation of integrated care at that systemic level?
Margaret:I won't try and talk about the international level. That's just way too remote and complex for most. But I think at a national level, we do have to begin to address the inequality in our community. And for me, that means the taxation system as a primary driver. But I won't carry on about that because friends and colleagues will be sick of my speeches about that.
Margaret:But I think that at that level, those sorts of things are are really very important. So, yes, taxation where someone owning 40 homes is not regarded as aberrant. I regard it as obscene. I think it's the community's decision to allow that to happen. I mean, good luck to them within the system.
Margaret:Use what's there, but for goodness' sake, change the system. Then I think we do need community leadership and and education, and we need that issue of a spectrum of use rather than, well, these people use, but these people are addicted. There is no cutoff. You know, this is a spectrum. It doesn't always go on a straight line.
Margaret:It goes up and down and around, and various people can be involved. So I think trying to get people to understand that there are various points of potential intervention or assistance that might be important. And in all of that, family members and friends or or important other people become vital. Because they are often this the extra support that we as professionals can't always be there, can't always provide.
Margaret:But that's also where peer workers and peer services are really helpful because they are often there when we're not. So I think at that level. I think the way services have been contracted out is really problematic because that's in the mistaken belief of the community that ensuring that things are run by organisations that are rewarded for efficiency, meaning cheaper delivery of, I would often say, symptomatic relief and out the door, means that people are not services are not rewarded for hanging in there with someone and following them up and checking on how they're doing and providing that extra bit of support when things are going off the rails. So I think the whole compulsory competitive tendering that has become the mantra of governments is a false economy. And I think not only does it cost us more in the end, but it costs clinicians pain.
Margaret:I mean, I think the administrative and funding end has thought and worked it out and split these into lots of services. And it's got to be compulsory, it's got to be competitive, etcetera. But at the individual provider level, it's incredibly frustrating and incredibly divisive and very disappointing. And it doesn't reward people for good professional care. So I think we've got to try and change the targets in contracts so that there are some other things that are measured and made as important as the numbers that you get through the door and you symptomatically relieve so that they're at least settled and out you go.
Annie:So bringing it back to person centric.
Margaret:Yeah. And I think that the services need because historically, whatever the administration were doing, professional staff, and I regard everybody who works in both mental health and alcohol and drug services as professionals, also had training in values, the community, communication. As well as knowledge and skills. And I think some of the training and the education has kind of gone a bit awry. It was seen as essential.
Margaret:When I first had the role of coordinating the alcohol and drug curriculum for medical students at Melbourne Uni, I had the opportunity to teach communication skills and run lectures on family and community and why they were important in any medical assessment. And I'm not sure that that is surviving those sorts of messages. So I think reflection, values, understanding culture, social circumstances, as well as people's personalities, their upbringing, the trauma, their experience, all becomes a part of what's really needed in the area of education and training early or postgrad and when they're out working. And Turning Point does a lot of that, I understand, Shalini.
Shalini:Yeah. I think we we still do. We still do a lot of that. And I think one of the factors as well is as the workforce has grown, we're really lucky to have, I think, a very multidisciplinary workforce. And I think there has been a fair amount of really turnover, in the workforce.
Shalini:So as new graduate trainees come through, it's always, rethinking about what is contained within training currently. How does that best fit needs in terms of the workplace currently? But I think from a policy perspective and from a, you know, policy that prioritizes kind of integrated care, I think one of the challenges for us, as you've mentioned, is some of this work can happen in in a relatively sort of patchy kind of context. And I think one of the things we'd love to see is really sort of that sustainability being prioritized too as a strategy, I think, in this space. Because I think one of the things that it comes down to in this competitive tendering environment is often up to individual services or individual providers or often altruistic providers or or people who would feel like they can go above and beyond in order to be able to cobble together.
Shalini:What's gonna work best. I think largely within mental health and drug and alcohol space, we're very good at that, in terms of the pragmatism and the cobbling. But I think outcomes frameworks in integrated care can be really challenging because to be able to tell that story of how, you know, when you've got someone sitting in front of you and you're seeing them actually being able to engage in life in a way that they couldn't, you know, a few months ago, you can see that.
Shalini:But to tangibly be able to translate that narrative into an outcomes framework that tells that story, I think that has really stymied the the integrated care field for quite some time. And I think partly, I think Annie had mentioned that sort of lived and living experience workforce, I think that is really kind of helping us transform how we think about outcomes as well. Because as Margaret mentioned, it's often more than just symptom remission alone. And I think many of the activity based funding models are about either episodes of care, so time and throughput, or they're about symptom remission alone or risk remission. But what we're actually kind of thinking about is trajectories of care, continuity of care.
Shalini:What does that look like for someone? How does someone often, you know, experience different parts of care across their lifespan? How is that stitched up across someone's journey, but also across the system? And so I think for the integrated care space, thinking about how we can prioritize work that actually tells that bigger story, that broader story, not just for an individual, but across a treatment system, across different sectors.
Shalini:I think that's really exciting work. And one of the things we often I think, Margaret, you mentioned that international context also being quite rich. I think what's interesting is there's been a lot of momentum too around kind of this focus, not just in the mental health and addiction space, but in chronic disease management around integrated care. And I think there's a lot we can can learn from. I think within just mental health and addiction alone, I'm thinking of initiatives that are occurring in sort of in The US or in The UK.
Shalini:The WHO and you and ODC have done a tremendous amount of work in thinking about how integrated care models can be delivered in Europe and then across low and middle income countries as well. So I think for us it's often not working just in a vacuum or in a context where we can build on work that's already been done over the last couple of decades. But because of, you know, the information sharing mechanisms we now have and the world feels a lot smaller after COVID as well, I think, you know, the collaboration aspect.
Margaret:Mhmm.
Shalini:We can kind of really learn from colleagues and build on each other's work and share work in a way that wasn't really something we could do a couple decades ago.
Annie:So as the clinical director of Hamilton Centre, where do you see the Hamilton Centre's place in this evolving process?
Shalini:Yeah. It's a it's an exciting space to be in. And I think, you know, coming out of the Royal Commission, clearly, there were lots of different kind of reforms that we could implement at the same time in Victoria. So I think for us it's been finding our feet in that space, in that very busy space, across the context and in clinicians' minds as well. A very busy space.
Shalini:But I think in terms of the next couple of years for us, I think as a centre and network, some of this work is about understanding what those foundational elements are to support kind of workers across those spectrums. And then I think particularly for the training and research elements of it, being able to, you know, craft some of these narratives, understand how, as a field, we can kind of move forward, how we can look at what best practice looks like in a way that's quite tangible for people to be able to implement in services. And so some of our work is about actually being able to look at that over the next kind of couple years.
Margaret:Yes. I think some of the tools available, including medication, so just to make a comment on medication because in my very early days, there were not so many appropriate or adequate medications. There were some emerging, and there were definitely some within the mental health arena. But they were still they were either being misused. So, you know, I can still remember the man who came in with his big plastic bag full of Valium tablets, just loose tablets.
Margaret:I said, where have you got those? And he said, well, I've been to the Repat, doctor, and I go there once a year, and they give me my year's supply. And that was in the day when the message was that you could not become dependent on benzodiazepines. So, you know, we have moved a long way. I think one of the difficulties is, though, that sometimes what we're seen as tools are seen as the answer.
Margaret:And so it necessary and it is very helpful to be able to use medication to help someone settle and to help someone manage their fluctuating mental state and various aspects of managing withdrawal, etcetera. But to think that that's the answer and leave it at that is really sad and I think so limited. And I think it's a sort of misuse of our technologies that we've now got available. I have been pleased to see, though, some use of some other technologies, you know, some of the counseling technologies that allow for versions of self help or guided care, secondary consultations that become available. And presumably, the AI era will produce and provide, helpfully a lot of extra thoughts, ideas, strategies, ways you might approach something, but it'll also probably provide a lot of noise and mess and false news.
Margaret:And I think trying to weed that out and sort it, I have to say I'm just relieved that I'm no longer responsible for all of that, and I can no longer pretend to keep up.
Annie:I think the Hamilton Centre has been very proactive in its writing and distribution of education modules, primarily to use correct language and to reduce that noise, as you say, Margaret. Shalini, would you like to just talk a little bit about those modules and their place in the broader community?
Shalini:Yeah. I think, you know, as you mentioned, Margaret, in terms of education and training more broadly, even at the undergraduate and postgraduate level, they can be quite variable in terms of people's trajectories and how they end up in the role they're in. And so I think some of those key elements around integrated care that are that are really common across different approaches, for instance, building on therapeutic relationship. How do you actually engage with someone? How do you have that conversation?
Shalini:You know, also modules around medication management, demystifying some of these processes for a multidisciplinary workforce as well. So some of these things are available through our Hamilton Centre online training modules that workers across the state can access. And that's self directed, but we've also, I suppose, designed it to enable processes locally where you can have colleague to colleague conversations, where you can have reflective practice and, you know, take those vignettes into your workspace and think about how would you have managed this? Could we do this differently? How do we do it right now?
Shalini:And so some of those modules are available. We also have training workshops that we've been running across the state, which has been fabulous because we've been able to kind of get into different places and see how communities are approaching different issues as well. So we're able to bring together different sectors in the room and think about things like care coordination or stigma. And so we've got some more of those coming up for the next year or so as well.
Annie:It's been a very busy time. I'd like to ask you both, as champions for health care workers, What's the most important lesson you've both learnt in your careers that you would then share with the clinicians of today?
Margaret:The important lessons from my experience are not necessarily all the knowledge or even some of the skills, but they're lessons about operating as either a clinician or a policy adviser or a negotiator in this space. And I think one of the most critical things is the importance of conveying care. It's probably one of the hardest things to actually achieve.
Annie:Can you just elaborate conveying?
Margaret:That you care about that person. You care about the problem they're talking about, the situation they're in. You care to understand and to know what they can do and their strengths, not just their problems and the difficulties or deficits. And I think that's been an important aspect of my professional role, not just around one to one clinical work, but also in the policy arena. If you're doing policy, you have to be familiar with the research that's current.
Margaret:You have to be ready to bring it to the fore, often at unanticipated opportunities arise, and you've gotta be ready to present it. Not say, oh, I'll go away, and I'll do the research, and I'll come back and tell you. You've got to be able to say, well, did you know that research has shown that using behavioural strategies in this situation can really be very successful. And you might only need to do this x number of times rather than this is going to require five years of psychotherapy or, you know, a thousand doses of the medication. So conveying care, identifying strengths and resources, not just in the person, but in their situation.
Margaret:So if they've got a best mate or a best friend or someone who's looking out for them, then let's use that and try to involve that resource as a strength. Because you might not be able to fix the things that are missing for the moment or difficult, but you might be able to further strengthen those resources. The importance of valuing clinicians who are on the front line and how hard it is for them to respond in the way that we're hoping for. The constraints on them, the personal constraints, the time constraints, the service constraints, the contract constraints are all complex. And it's highly likely that they will also be written in their own way with internal conflicts of values.
Margaret:They'll have personal values. They'll have professional values. They'll have service organization values. They'll have values from the society. And they're not always aligned.
Margaret:And trying to find ways of reconciling or dealing with those contradictions becomes really important. Something I've often thought to focus on in supervision. How do people reconcile those contradictory values? This is what I want to do for this reason. This is what I am allowed to do.
Margaret:This is my you know, this is what I can do. And just really have a chance to explore that and assess what is the most meaningful and most pragmatic thing I could do in this situation.
Annie:And have care at the centre of that.
Margaret:Yeah. And probably the most important part of caring is being willing to listen. And I mean active listening, not just, okay, I'll fill this out or I'll do that while I'll get the script ready or I'll check the boxes while you're telling me your life story. Most people will take an opportunity to tell you something, but we don't always take the time or the focus to listen.
Shalini:And I think, drawing on that, Margaret, I think in prepping for this podcast, that's exactly what I was thinking is being the most helpful lesson that I've kind of picked up on the way because I think we work in environments where, as you said, lots stuff can get in the way of being able to be there and be present and be mindful and listen. And I think also, as we mentioned before, the Royal Commission implementation, there's lots of noise as well. There's lots of busyness. But I think the capacity, of, you know, you might be going into a consultation, you might be seeing someone, you might not even necessarily know much about what they're presenting with. I think often you're working outside your area of familiarity, outside your comfort zone, like, that can itself bring a lot of noise, I think.
Shalini:But, you know, we always have the capacity to be able to really just be there and listen and seeking to understand rather than seeking to judge, being able to kind of, you know, hear what someone's telling you. And it may not just be the story that they're telling you, but what's coming along with that, you know, the emotions that the person's telling you about, and their family, as you mentioned, and who is connected to them. And having the space to be able to actually do that and reflect on it as well. I think as clinicians, we're very privileged to be able to do that across our careers, and that's often what brings people to this profession, I think, helping profession in the first place. So really valuing that and being able to find space for yourself to be able to engage in that.
Shalini:And I think related to that, I think a similar lesson, which is actually an organizational value, I realize, for our organization, Eastern Health, It's really around sort of humility and respect. I think we work in a incredible environment where we get the chance to work with lots of people from different professions, from disciplines and backgrounds. And I think it makes a very rich kind of conversation, rich kind of discussions about particular policy topics, for instance, or clinical discussions. I think in that space, being able to always be open to kind of learning and seeing things from other people's perspective and learning from others, that's been a really incredibly valuable lesson. And I think in integrated care it's really central to be able to understand how we do things better, is being able to hear how other people do things and learn from others as well.
Shalini:So that's been something I found really helpful.
Margaret:I think that issue about what brings people to this field, I've never really met anyone who said, at the beginning of my career, what I always wanted to do was work in addictions. Similarly, I've never met a consumer of services or someone who needs services who said, I've decided I need to change my drug use. So I always used to ask of people who came to the clinic in my early days, and then subsequently to Turning Point, we would try to understand, why have you come now? What's the crisis behind this presentation? And I think the same issue sits with mental health, that if you can't get to the nub of the immediate crisis that has actually provoked help seeking, you're not going to engage them.
Margaret:To be engaged, you've got to respond to that even though you, as a professional, might think you see a much more urgent problem if you don't deal with the reason they've come. And I do recall a little story of a man who came in one day with a flower pot. It was such a beautiful hydrangea, quite a large one. He was a homeless fellow who I knew and had used to come fairly regularly to the clinic. And he had a lot of difficulties, physical and mental.
Margaret:And I'd managed to get his bank account to only be available to him every second day. So instead of having one huge binge every fortnight and wiping himself out and doing more brain and liver damage and all the other bits, he would taper it across two weeks. He came in with his flower pot and he said, there you'll love it. You're a nice bitch. And I said, okay.
Margaret:Why have you brought that? But more importantly, where did you get it from? He said, oh, there's a big show on over at the over at the gardens in that glasshouse. And no one was looking, so I thought I'll bring you one. And I said to him, what's behind that?
Margaret:You know, are you wanting to thank me? I doubt it. He said, no, love. I'm hoping you'll report me. I'll get picked up.
Margaret:I'll get charged. With a bit of luck, I'll get three months because it's about to be winter. And we had lots of people who would try to get into prison for a short term so they could have cover, food, security in their own way across winter rather than sleeping rough. And it taught me a lot about that issue of listening, inquiring, and as you said, Annie, being curious.
Annie:And can I ask, being curious, what did you do?
Margaret:I rang the police. I said, look. I've got an awkward situation. I've got this flower pot. I do know where it came from, and I know who picked it up.
Margaret:They said, oh, it was probably so and so. And I said, yeah, was. He said, yeah. We we've we know he's taken it. I said, well, will you charge him?
Margaret:They said, yeah. We'll bring him to the watch house, and with a bit of luck, we can help the magistrate order, you know, three months. And I just thought, he knows his way around this system, and I learnt from him.
Annie:Or maybe the police were looking out for him as well.
Margaret:I doubt it. I think well, I think looking out for him in the sense of wanting to support him in in what he was yeah. In his needs.
Margaret:But, I mean, they could, and they would. And that's very different to someone who is, you know, violently aggressive and causing major disruption or family violence or something. But it, nevertheless, was a valuable lesson.
Annie:So if I wave my magic wand and you have one key wish, what initiative would you like to see, Margaret, implemented across the integrated care landscape?
Margaret:Time. That everybody who works in a service has an opportunity of time. If they don't have time for everyone who's presenting, that their seniors and supervisors give them time with one or two people and recognise that and help to protect it so that they can learn from that experience, be it in supervision or in some other way. I think that sometimes the advantage of something like conferences or meetings because people it's not just they hear ideas. They get a chance to hear the ideas and stop and think.
Margaret:And I think that's the thing that would be my wish, that you can somehow generate time for workers.
Shalini:I think my wish, Annie, is very similar wish, but at the service and system level is time for a sort of implementation and time for sustainability. I think often wishes come from points of frustration, I suppose. And one of the points of frustration can come from lots of sort of pilots or little, you know, magical pockets of excellence that exist in this area. You hear about this all the time that, you know, a service is set up some exemplar of of really amazing, service delivery. But often these are small sort of time limited, opportunities where we don't necessarily have then the opportunity to scale it or implement it more broadly.
Shalini:And so I think thinking about that longer lens of time for system implementation and thinking about how do we actually embed some of these things so we're, you know, actually moving that goalpost forward, we're not actually, you know, continually sort of reinventing the wheel. I think having sustainability at the core focus of integrated care is part of that.
Margaret:And having some version of evidence grounded approaches to things that would allow for that.
Shalini:Absolutely.
Annie:Because it's interesting, as you say, Shalini, sometimes these initiatives are time limited, but people's individual issues, health issues, are just so long standing. So it's incongruous really that even happens. Margaret, can I just revisit your comment about strength based approach and celebrating the strength of our clinicians, but also the strength of the people that seek the services for their mental health issues or their drug and alcohol issues, as well as the families and carers? How do you think that we can actually promote this approach throughout the industry?
Margaret:I think it's necessary for everyone involved to start with themselves, the professionals, and in a sense say, what are my real assets as a clinician, as a support worker, as a friend, whatever? And how can I use that most appropriately? One of the difficulties sometimes is that we sort of have a very limited menu of offerings. And so whatever someone comes in and presents, we say, well, this is what we do here. So I can give you this. And that's why I say listening and caring is really critical. So I think starting with people who are doing training or clinical work, thinking these are the bits I'm really quite good at. I can remember learning that I was a better graphic learner than I was text, for example. And I didn't learn that for a long time, but I learned it partly through my research groups because I would always say, let's go and have a coffee, and then I'd find myself with a serviette and doing drawings and diagram of what I had in mind as a new idea and saying, look, I think because of this and this, then I think we should try to do that.
Margaret:And one day, a person who was an OT said, oh, you're obviously a graphic operator, a graphic learner. So I learned that even in most roles, we'll have preferences. And I think one of the things we can usefully do is think, what are my preferences and what are my strengths and what do I find more difficult? And sometimes, some situations, I can use my strengths to help deal with things I find difficult.
Margaret:And I think trying to, in a sense, train people to be self reflective as well as reflecting on the person can really help with that.
Margaret:I used to run supervision groups way back and then subsequently supervising research or supervising policy groups, etcetera. And in the clinical domain, I used to get people to say, okay. So from that session you've just had with someone, choose five minutes and try and just write down the dialogue exchanges. And they would bring it to me, and then I would say, okay. And what else happened that you didn't write down?
Margaret:And they'd say, oh, no. That's pretty much it. I said, really? Why did you choose that five minutes out of that twenty minute? I'd say, oh, it was difficult, but I think I managed it quite well.
Margaret:I said, that's why I want you to talk about what else you thought about or you didn't think about or you did do or what you would do differently if you were in that situation again. And they would often say, well, actually, I did say such and such, and that didn't produce very useful things. So I just left that out, and then I went on to this. And that's the self learning that we need to be able to use ourselves, share with people we work with, but also share with those who come to our services. So the consumers of services need help to reflect and to learn from their own life experience.
Annie:And to identify their strengths.
Margaret:Yeah. And to say, actually, I'm quite intelligent. I once had a guy who was extremely good and had gone through what was then matric and done maths and was a whiz. And he was subsequently a guy who was nonfunctional, not working like fifteen, twenty years later. And when I said to him, what's the best thing you've ever achieved?
Margaret:He said, probably matric. I said, any particular subject? He said, oh, maths. I said, can you still do maths? He said, probably.
Margaret:So I got him involved in a project that we had where we needed someone to do some budget stuff for us. And he insisted on using a red pen. I said, why do you have to use a red pen? He said, because that's what the teachers always use, red pens, and they rule through things. And I just think if I've got the red pen, I'm in charge.
Annie:Nice.
Margaret:So I think you can usually find, you know, creativity is quite critical as a clinician. You have to be able to think of a question, not just use the five that are given as a guide. And so on that occasion, I thought, this guy there's more to this guy. I said, you're you're actually very bright. And and then he said, oh, well, I probably am.
Margaret:But I've, you know, I've wrecked my life or I've whatever. So what's the best achievement? No one told me in guidelines ask about the best achievement. But, yeah, those sort of being a bit creative in the moment, I think, is really helpful because then you can build on that and they can say, yes, I can do that or I can make decisions. Or I have got a friend who I haven't seen for a little while.
Margaret:I could make contact. Or I can go to a meeting where there are other people who are also currently not drinking or not using. Because even though I don't think much of a lot of them, at least it's somewhere else to be for that hour. And so time structuring becomes so important to people, particularly in addictions.
Margaret:Yeah. So yeah. Creativity.
Annie:Any creative thoughts?
Shalini:Any creative thoughts. I guess one of the things we're talking about at the moment is is around kind of thinking about our own strengths and self reflection as well. And sometimes that's also, you know, a sacrifice of time, think, when in the workplace that supervision, but also self reflection kind of quickly go of, you know, protecting it or looking after that. But I think, particularly when we work in sort of complex busy environments, I think I've learnt over time to really protect that. I think the self reflection is sometimes part of training too.
Shalini:I think that's certainly part of the training that I really valued as a psychiatrist kind of central to part of the training is knowing, you know, knowing yourself, knowing what you're bringing to each interview, each session with people. And as you say, Margaret, when you're kind of reflecting on how an interview went or how a conversation, why some points and not others, you know, nonverbal body language, etcetera. What else in that space? It's amazing how much richness can happen actually in an interaction when you've got capacity to kind of look at it and think about what's happened.
Shalini:But I think also using yourself as a tool, I think, is part of that process. And, particularly, you know, when we work across flexibly and integrated care across kind of psychotherapeutic interventions. You're very much part of that intervention itself. The, you know, the core centrality of sort of therapeutic alliance, it's the most important predictor of whether any type of psychotherapy works at all, really. It's it's actually that relationship between the individual and the and the worker.
Shalini:It's it's that space that actually drives whether this is gonna work or not. And so, you know, as much as what the person's bringing to the room is also what you yourself are bringing to the room. And I think in integrated care, that can be about a knowledge base, but it also often is about a a humanness, like actually thinking, how can I be authentic in the space? You know, often, as I mentioned before, it might be an area that's not familiar or comfortable for me. So then how do I call that?
Shalini:How can I actually, you know, ask people, invite their curiosity as well into the room and kind of help people who are often the experts of of their own experience as well, being able to to share with me and and have an authentic conversation about what's going on? Yeah. So I think the capacity to be able to kind of self reflect and to to prioritize it and value it as well, that's really helpful, I think, in this type of work.
Annie:And that's a really nice message, I think, to end the conversation on about the authenticity that's required and the listening and the care that's required to deliver meaningful integrated care to people with alcohol. And other mental health issues.
Margaret:Perhaps there's one other thing that I think is important. It's a willingness to say thank you.
Annie:Oh, yes.
Margaret:So for me, I will often thank a person who's come to a service. I will thank colleagues. I will thank, on this occasion, my husband, Bill Healy, and my stepchildren, Anthony, Catherine, Elizabeth, and all their families, and my kids, James and Claire, because as well as all those other odds and ends I've done, I couldn't have done that, and I wouldn't have done that if I hadn't also been a partner, actually a wife, a mother and a grandmother of numerous grandchildren. And my tired voice at the moment is that I've got a cold from the 18 old grandchild that I've been caring for. But I think I thank you.
Margaret:And thank you to the various professional people and mentors that I've had over time much earlier on in my career.
Annie:That's beautiful, Margaret. And we're really grateful for your time today. And thank you both for sharing your valuable insights and experiences. It's been a real pleasure having you on this podcast. It's very exciting that it coincides with our second anniversary, and we just loved hearing your perspectives.
Annie:Thank you.
Margaret:Thanks for the opportunity.
Shalini:Thank you.
Annie:Thank you for joining us on the Hamilton Center podcast where we explore the thinking of leaders, service providers, workers, and people with living and lived experience shaping the landscape of integrated care in mental health and addiction services across Victoria. I'm Annie Williams, your host today, and we can't wait to share these insights with you. Visit our website, ww.hamiltoncenter.org.au, and subscribe to our newsletter for a journey into transformative mental health and addiction care.