Photo credit: Harm Reduction Coalition
The harm reduction approach grew out of the HIV epidemic during the 1980s, although the roots of this philosophy extend further than that. People who inject drugs became aware of the increased risk of contracting HIV by sharing needles and they spread information and resources to one another. Following their lead, providers began offering needle exchange programs to reduce the spread of HIV and other infectious diseases like Hepatitis C. The strategy was successful around the world and proved what is possible when people who use drugs are informed and empowered. The origin of harm reduction is in drug users helping other drug users. But the utility of harm reduction is not limited to needle exchanges or supervised injection facilities. We limit our impact when we don't harness the full potential of this compassionate and pragmatic approach.
The principles of harm reduction can be applied to our engagement with people around any risky behavior. Practicing harm reduction means partnering with people to identify problems and potential solutions, avoiding judgment and respecting their choices, being patient with the change process, and promoting continued engagement. The measure of success of this approach is improved quality of life. These practices are not exclusive to working with people who use alcohol and other drugs. Experiencing connection and empowerment are healing factors, no matter the ailment. Let’s take a look at how harm reduction can help with other risky behaviors.
Homelessness itself is risky and exposes people to numerous harms. The ideal solution is housing, but that option isn’t always readily available to people. The experience of homelessness disempowers. In a shelter, you are constantly living on someone else’s timetable. On the streets, you are more vulnerable to the weather or violence. While people are living in the streets and shelters, we can help them recognize what is in their control. Through these conversations, they can identify strategies to improve their safety and quality of life such as strength in numbers, avoiding people who seem dangerous, and finding meaningful activities to engage in during the day that break up the monotony while adding opportunities for structure and connection.
It can be a lot of work to eat healthy, not to mention expensive. It’s even more complicated when you’re eating whatever a shelter or pantry has to offer, have limited means to buy food, or live in a food desert. Using a harm reduction framework, we can help people develop low-threshold strategies to improve their nutrition. Gaining access to government benefits or food pantries, keeping canned or frozen vegetables in the home, and choosing inexpensive proteins like peanut butter or beans are just some of the strategies that may be within reach.
When we use a harm reduction approach, we take a sex-positive stance in frank discussions about people’s sex lives and ensure that they have access to barrier protection and STI testing. But, we don’t shut down if our participants tell us they don’t use condoms. We explore their reasons and help them seek other opportunities to reduce risks associated with sex like being selective about partners, other forms of contraception, and safer types of sexual practices.
A few years ago, the theme of our Harm Reduction in the House conference was “It’s Not Just About Drugs”. The conference looked for the risks in our participants’ lives beyond those associated with their substance use. People experiencing homelessness navigate chronic health problems, encounters with the police, and intimate partner violence to name a few. Participants in Housing First programs face all these situations and more. In every situation, there are opportunities to reduce their potential to harm. Using harm reduction to engage with participants about these risks will affect the options they recognize and the choices they make. In many ways, every year of our conference is about this theme as we continue to look for populations and situations that might benefit from a harm reduction approach. Join us for our conference this year on September 23rd in Chicago and help us expand this conversation.
In future posts, we’ll explore how harm reduction can be applied to other challenges our participants face like managing mental health.
This is the final post in our series on the Critical Ingredients of Housing First. So far, we’ve covered the other essential elements for implementing an effective Housing First program—a low threshold admission policy, reduced service requirements, separation of housing and services, consumer education, and eviction prevention. Our future blog posts will focus on other aspects of working in a housing first program, looking in-depth at harm reduction in service delivery, and other topics relevant to the people involved in Housing First programs.
Harm reduction is a pragmatic approach to risky behaviors. Harm reduction recognizes that most of us regularly engage in activities with the potential to cause harm including sex, driving, sports, and alcohol or other drug use. People get something out of taking risks. Whether it’s a means of feeling good or relieving pain, we do potentially harmful things, and with good reason. Instead of only trying to eliminate these activities, harm reduction connects with people by avoiding judgment about their behaviors, expressing curiosity about both the benefits and costs, providing resources to do it in the safest way possible, and shifting the focus to improving the quality of life for the individual and their community.
Harm reduction recognizes and employs a broad spectrum of strategies to minimize or remove harm. Yes, that includes abstinence! Harm reduction supports any effort to reduce harm that people choose for themselves. Traditionally applied to substance use, the philosophy of harm reduction has been incorporated into social service agencies’ work with their participants around all potentially harmful behaviors. In order to successfully practice Housing First, we need to incorporate a harm reduction approach to service delivery.
As we discussed in an earlier blog post, the Housing First model is based on the principle that housing is a human right. That means that we should not only provide housing resources to people who are practicing abstinence from drugs and alcohol. If every person who uses these substances were homeless, there would be millions more people living on the streets and in shelters. While the issues participants face can create challenges in maintaining housing, they are not insurmountable nor are they grounds to deny a basic human right. Harm reduction providers protect the right to housing by focusing on the consequences of drug use (e.g. nonpayment of rent or excessive visitors) and not just use itself.
Blocking access to housing programs based on drug use alienates the most vulnerable members of our communities experiencing homelessness. As a study on the Collaborative Initiative to Help End Chronic Homelessness highlights, nearly 3 out of 4 people experiencing chronic homelessness have a substance use disorder. People who are homeless and have a substance use disorder must be offered the same options and rights as other people who are homeless. If Housing First is to succeed, substance use can no longer be a barrier to accessing housing. Homelessness does not cure addiction; stability, connection, and unconditional support do.
Homelessness does not cure addiction;
Housing is a powerful motivator to get a person’s foot in the door and link them to a case manager or community-based support team. The harm reduction approach is what keeps them engaged. In Housing First programs, participants have a reduced level of fear about losing their housing, which improves the quality of their relationships with staff. One Housing First participant explained: “I mean that’s scary when your housing is tied to your ability to remain abstinent. I mean you live kind of in a constant fear…It’s not conducive to remaining sober with that kind of pressure and it’s not conducive to remaining housed…It’s a huge relief when you realize your housing is not tied to your ability to remain abstinent.” Establishing a relationship where it’s safe to speak openly about drug use is difficult. Our participants have been conditioned to avoid the topic since it typically leads to doors being closed on them. By allowing participants to be honest, harm reduction can help participants go beyond all-or-nothing thinking and look for ways to mitigate potential problems associated with their drug use.
Harm reduction embraces the belief that participants are experts in their own lives. They are best equipped to define the problems they face, as well as their goals and strategies to overcome them. Harm reduction workers support participants by ensuring they are informed about the potential harms of risky activities and how to improve their safety. Harm reduction strategies in housing include meeting a person’s most basic needs—eating well, getting regular sleep, and paying rent first to maintain the security of housing. Simply attending to these needs can offset some of the greatest harms caused by drug use or other risky behaviors. While we can’t guarantee that people will always make the safest choice, harm reduction ensures that they are making informed decisions about the risks they take and accepts their right to choose for themselves.
Ultimately, Housing First is a harm reduction approach to housing. It creates access to resources for participants without requiring that they meet predetermined outcomes, engages collaboratively with them about their concerns, and respects the choices that they make. As one Housing First staff member said, “Harm reduction and Housing First are working hand-in-hand. You can’t have one without the other, you just can’t.” Housing First gives us an opportunity to reach the most vulnerable people experiencing homelessness and help them secure the supports they want and need. By fostering trusting, therapeutic relationships harm reduction helps people recognize and make use of opportunities for positive change. It shifts our focus away from completely eliminating risky behaviors and onto the person's well-being.
Evictions are a growing problem across the country. In his new book, Evicted: Poverty and Profit in the American City, Matthew Desmond shows that evictions are more common now than they were at the time of the Great Depression. He details the toll that an eviction takes in destabilizing people’s lives beyond just creating difficulties finding housing in the future. In an interview with Desmond on Talk Poverty Radio, they explain that mothers have higher rates of depression two years after an eviction and note that the number of suicides attributed to eviction or foreclosure doubled from 2005 to 2010. Although our participants benefit from the assistance of subsidized housing, they are vulnerable to eviction because they possess few economic resources and might not have recent experience maintaining housing. For too many people, eviction results in homelessness. That is why it’s essential that we practice eviction prevention in Housing First programs.
Eviction prevention is a case management intervention that incorporates planning with participants to prevent lease violations and advocating with the landlord or property manager to allow staff to work with the participant to curb lease violations when they come up. In addition, case managers can negotiate with landlords to allow people to move out without going through a formal eviction as well as rehouse participants when an eviction does occur.
The threat of eviction is typically triggered by a lease violation. Common lease violations we see in Housing First programs include falling behind in rent payments, having excessive visitors, instigating noise complaints, or engaging in illegal activities such as buying and using drugs. Although many of these issues may be related to alcohol or drug use, Housing First programs should focus on behaviors and consequences, as opposed to dwelling on use itself. One Housing First participant explains how staff worked with them to avoid eviction: “Probably six or seven months after I moved in, I relapsed. So, I went through a period of drug addictions…They actually helped me out. I had fallen behind on rent for a few months, so they gave me the opportunity to make up the rent that I hadn’t paid.” Using a Housing First approach increases flexibility and allows us to be creative in helping people maintain housing. These proactive conversations may include budgeting to make sure the rent is paid or strategizing to buy drugs in a safer way. Despite the fact that a person may be using drugs, these harm reduction strategies can help people to avoid displacement and a return to homelessness. If we believe housing is a human right, we must work to keep people housed even when they struggle with meeting the terms of their lease.
Landlords should be our allies in the fight to end homelessness. At the end of the day, landlords want the same thing that our participants want—a safe, stable home. There are benefits for landlords who work with housing programs. One of the greatest advantages for landlords is increased communication and accountability. By working with case managers, landlords have a contact person who can mediate any problems that arise. Case managers can address landlords’ concerns and offer assurance that problematic behaviors will be addressed. At the same time, case managers thoughtfully relay this information to participants and develop their tenancy skills to increase housing stability. If our advocacy falls short and a landlord is set on evicting a client, we may still be able to negotiate with the landlord and offer to move the person out before a formal eviction takes place. By responding quickly, we can maintain our relationship with the landlord and prevent the participant from being burdened by having an eviction on their record.
If people are going to be evicted, the best practice is to get them housed again as quickly as possible. If we don’t plan to continue working with a participant to rehouse them, it reduces the incentive for them to move out prior to a formal eviction. At our annual Harm Reduction in the House Conference a few years ago, Patt Denning said about rehousing people, “It’s the staff’s job to house people. If someone loses housing, you house them again because that’s what you’re paid to do. But, remember this will go a long way to reducing your harm of burnout.” Denning points out that rehousing is better for the participant and provider alike. Eviction hurts. It hurts our participants and it hurts us because we care about them. Eviction prevention provides us with an intervention to avoid this pain.
The Housing First Model shifts how housing resources are distributed. One critical change, which is closely connected to the Low Threshold Admissions Policy, is the reduced service requirements in Housing First programs. In traditional programs, access to housing was earned through measures of housing readiness like abstaining from drugs and alcohol, getting a job, or engaging in regular medical care. In a Housing First program with reduced service requirements, people are not expected to jump through hoops to prove they are worthy of housing. There is no mandate to attend peer support groups, group therapy, inpatient treatment, psychiatry appointments, or other services. The options are offered and explored, but the decision to participate is left up to the participant. Service requirements in the strongest Housing First programs are limited to regular contact with a case manager. That case manager engages with the participant about issues they face and increases contact with them when they first move in and again later if they are struggling to maintain housing.
One fear of providers shifting to the Housing First approach is that people will not take care of themselves if they aren’t forced to do it. An early study of Pathways to Housing disproved this notion. The study compared a group of people who were homeless and entered two housing programs—one based on participation in substance use treatment and requiring abstinence (Control group) and the other using Housing First (Experimental group). Although a greater number of people in the Control group engaged in treatment (after all, they were required to do it in order to access housing), there were no significant differences in the rates of substance use or mental health symptoms between the two groups. The Housing First participants obtained housing faster and reported greater levels of perceived choice and autonomy.
Research shows that choice matters in recovery. As one study explains, “providing people with more choices predicts better outcomes for people with severe mental illness.” Stigma around mental health and addiction fuels a false notion that people living with these conditions lack the ability to make rational choices. Housing First disproves that assertion and emphasizes consumer choice at every turn—from housing selection to service participation. Participants are not burdened with benchmarks to meet in order to access or maintain their housing. Instead, housing maintenance is based on meeting the terms of their lease like everybody else. Their participation in services is based on their own choice. As one Housing First staff member explained, “It actually puts a lot of responsibility on the consumer.”
In our trainings on motivational interviewing, we often reference a quotation from Blaise Pascal, who said, “People are generally better persuaded by the reasons they themselves have discovered than by those which have come in to the mind of others.” Just as people are more inspired by their own reasons, Housing First believes people are more committed to goals and solutions they develop for themselves. While we may be able to force someone to make a change for a short time in order to get into a housing program, that isn’t the recipe for creating lasting change. We trust that people are motivated to improve their own lives and best equipped to decide how to do it. Housing creates stability which enables people’s pursuit of positive change. People don’t change because we want them to; change happens when people are ready and find the solutions that work best for them.
As discussed in an earlier blog post, the Housing First model is based on the principle that housing is a human right. If that’s true, it means that we shouldn’t create conditions that limit access to housing. As much as we want to support individuals in pursuing their goals by engaging in additional services, it should not be mandated in a Housing First program. When people feel like they are respected and their perspective is valued, they are more likely to pursue other supportive services. Housing First encourages access and choice to promote positive change.