In our country, mental health treatment increasingly emphasizes the use of psychotropic medications. As we’ve searched for the magic bullet for these complex conditions, we’ve moved away from other forms of support, like psychotherapy. This shift has occurred despite evidence that medication is most effective when it is coupled with therapy. From the outsider’s perspective, the solution to someone’s mental health problems can appear simple: “Just take your meds”. Too often, we believe that medicine is completely safe and effective because it was prescribed by a doctor. This can be a dangerous assumption. Psychotropic medications are drugs—they can positively affect a person’s mood or state of mind but they also have the capacity to harm. Providers can use a harm reduction approach to engaging with participants about psychotropic medications to ensure that they are used in the most beneficial way possible.
Our participants have the right to choose whether or not they use psychotropic medications. We should acknowledge their experience and autonomy. Nobody is better equipped to describe the effects, good or bad, of a medication than they are. Just like the decision to use drugs must be respected, sometimes our participants will decide that their best option is to not use psychotropic medication altogether.
A harm reduction approach to psychotropic medication means it is not framed as a requirement for mental health treatment and recovery. Instead, medication is presented as an option to be considered. The job of a case manager is to help participants make an informed choice. Participants have legitimate reasons not to use psychotropic medications, often based on previous negative experiences. We should ask about these reasons and take them seriously, refraining from judgement. Harm reduction workers provide space for participants to discuss how their choices are working out and regularly engage with them about the risks and benefits of their choices. But, these conversations can be challenging. This article offers some information and resources to help guide you. The two issues we’ll focus on are medication adherence (i.e., the extent to which people follow a health care provider’s advice about a medication and how to use it) and how to come off of psychotropic medications.
Non-adherence, or not taking medicine as prescribed, can be risky. Research links non-adherence to psychotropic medication with poor outcomes like hospital admissions and suicide. However, non-adherence is not unique to people with a mental illness. Rates of non-adherence to psychotropic medication are comparable to those for physical medications. A lot of things can factor into whether or not a person takes medication as prescribed: the information or understanding the person has about the medication; the degree of improvement or side effects they experience; their ability to afford the cost of the medication; their ability to remember to take the medication or refill their prescription when needed; and the approach of the health care provider prescribing it to name a few. Exploring the barriers to adherence can help them identify strategies to overcome them.
Some effective options to improve adherence include the use of long-acting injections of antipsychotic medications or medication monitoring through community support. However, a relapse of mental health symptoms is still possible while remaining adherent. So, we should talk to participants about their medications and how they are working for them. Even if a medication has been useful in the past, it’s important for participants to continue regular follow up with the prescribing provider to keep an eye out for unwanted side effects. Rxisk is a website dedicated to making medications safer by educating people about the risks and side effects associated with them. Among other resources, it provides a checklist of questions for patients to ask providers about the medication they are prescribing. Case managers should also research and be aware of potential side effects of the medications that the people they work with are taking, so that they can educate, monitor, and check in with them regularly.
When participants choose to stop taking psychotropic medication, case managers should aim to be involved in the conversation and encourage people to involve their psychiatrist in the process as well. The potential for withdrawal with many medications is real. As with other drugs, like heroin or alcohol, our bodies can get used to the presence of certain chemicals which makes it difficult to adjust when they are no longer there. Sometimes the symptoms of withdrawal (e.g. anxiety or sleep problems) can mirror the symptoms of a mental illness or exacerbate them. Remember that even when withdrawal symptoms are present, it is possible to successfully come off of psychiatric medication altogether. For an in-depth guide on this process, check out the Harm Reduction Guide to Coming Off Psychiatric Drugs and Withdrawal from the Icarus Project and Freedom Center. In general, tapering off of these medications is safer. A guiding principle to keep in mind is that the longer someone has taken a medication, the longer it will take to safely get off of it. As with taking medication, the process of coming off of them is one that we should engage with our participants about to review their progress and help them revise their plan as needed.
Medication can help or hurt people’s efforts to manage their mental health. Open-minded conversations about the pros and cons of using psychotropic medications encourage honesty from our participants about their level of adherence to a medication or their ultimate desire to stop using it. In a future blog post, we’ll address other strategies for managing mental health. With or without medication, recovery is possible.
As service providers, we can be part of improving the safety of LGBTQ communities by ensuring access to the basic human rights of housing, health care, and necessary supports.
The country is still reeling from the Pulse Nightclub shooting last weekend that left 49 people dead and many others injured. As we mourn the lives that were taken and for those families and communities that will forever be impacted, it is important to remember this tragedy is one event in a long history of violence against a specific community, and to recognize the trauma many of those who identify as Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) face on a daily basis.
People who identify as LGBTQ are disproportionately at-risk of experiencing violence—childhood abuse, sexual assault, intimate partner violence, harassment by law enforcement officers, and hate crimes. This is especially true for people who are trans-identified. In addition, members of this community are disproportionately affected by poverty and more likely to experience homelessness than others in our society.
The risk of violence and homelessness is increased for sub-groups of the LGBTQ community with intersecting vulnerabilities like youth, women, or people of color. Despite being only 5% of the total population, between 20-40% of homeless youth identify as LGBTQ. One recent study from Georgia State University found that over 28% of homeless and runaway youth in the metro-Atlanta area self-identify as LGBTQ. Among the victims of LGBTQ hate crimes resulting in homicide, people of color are disproportionately impacted. This is represented by the fact that the Pulse Nightclub shooting took place on Latin Night.
The pain of this moment highlights the need for competent services for the LGBTQ community in homeless and allied social services. We have a responsibility to create safety and security for the most vulnerable members in our communities. But, our organizations and programs are often not structured to sufficiently meet the needs of LGBTQ participants. In shelters and service programs, clients are often turned away, unable to express their identity, or not offered appropriate services. As service providers, we can be part of improving the safety of LGBTQ communities by ensuring access to the basic human rights of housing, health care, and necessary supports. Increasingly, there are discussions happening about how agencies and service providers can be more inclusive and supportive of people who identify as LGBTQ. For instance, the National Coalition for the Homeless and the National Gay and Lesbian Task Force teamed up to create Transitioning Our Shelters, a guide for making homeless shelters safe for people who are trans-identified.
This symbol can be used to indicate that your office is a safe(r) space
Improving the ability of service providers to meet the distinct needs of LGBTQ participants begins with education. Staff and participants alike should be continually trained in cultural competency around LGBTQ issues. We should recognize that our words can be harmful. To avoid that, staff can use inclusive language (e.g. partner instead of husband/wife or boyfriend/girlfriend) and differentiate between sexual orientation and gender identity. We should ask people in our programs about their gender identity and allow them to identify this for themselves. Respect is then further reflected by using people’s appropriate pronouns and chosen names. We should not ignore when LGBTQ participants experience harassment from other participants in our programs but instead encourage respect as part of being a good neighbor and community member. We can make our services more welcoming to LGBTQ participants by offering gender-neutral or single-stall bathrooms in our facilities and simply having honest conversations with these participants about what we can do to increase their sense of safety in our programs. We can also partner with LGBTQ organizations for help with questions and additional resources. This is only a sampling of some of the things we can do to make our agencies and programs more inclusive.
In addition, we should hire people in our organizations who identify as LGBTQ. I am a homeless service provider and an ally of the LGBTQ community. But, without the lived experience of homelessness or identifying as LGBTQ, my ability to understand is limited. Hiring people who identify as LGBTQ and formerly homeless reflects a desire to be representative of the communities we serve and provide spaces where they can feel safer.
The LGBTQ community is vulnerable but strong. One example of the community’s resiliency is the Transgender Housing Network. This group maintains a website that is a temporary housing network connecting trans people with safe and supportive places to stay. Similarly, RAD Remedy is a new website linking people who are trans, gender non-conforming, intersex, and queer to safe and respectful healthcare services. These groups are responding to an unjust system that limits the ability of people who are trans to access adequate housing and healthcare. These are true examples of harm reduction—a community of people exposed to risk and responding in a way to make themselves safer. But the LGBTQ community should not have to do this work alone. Service providers should figure out how to join the efforts that this community is already making to gain security. As programs and agencies committed to social justice, we are all allies in the fight for LGBTQ inclusion and protection.
This post was written by our research partner Dennis Watson, MA, PhD
Center for Health Policy
Indiana University Richard M. Fairbanks School of Public Health, Indianapolis
*Reprinted from Indianapolis Recovery Coach Newsletter
The U.S. Department of Housing and Urban Development’s (HUD) annual homeless census counted 4,694 adults experiencing homelessness in Indiana this past year. Of these individuals, 596 were chronically homeless (meaning they have a diagnosed disability and have experienced continuous homelessness for at least one year or have been homeless at least 3 times in the past 4 years), 933 had a chronic substance use issue, and a significant number of those individuals with substance use issues are likely experiencing a co-occurring mental health problem. A treatment first mentality (requiring individuals to address substance abuse and mental health issues before accessing necessary services) among providers is a significant barrier to needed services many individuals experiencing homelessness face. However, new trends in homeless services drawing upon the principles of harm reduction are resulting in improved outcomes for this population.
Individuals experiencing homelessness often have difficulty meeting demands of programs requiring abstinence or participation in substance use services because they are not ready to give up their substance use. In many cases, this is because behaviors providers see as negative are providing some sort of benefit to the person in light of all of the adversity they experience on the streets. In cases where individuals do obtain abstinence for the purpose of accessing services, relapse often follows because their end goal was the service (which has been obtained) and not sobriety itself. Harm reduction is a more practical avenue for working with members of vulnerable populations who have experienced significant levels of trauma, as well as individuals who are simply not ready to choose sobriety. While many individuals see harm reduction and abstinence-focused approaches such as Alcoholics Anonymous as being in opposition to each other, harm reduction is actually highly accepting of abstinence as a goal as long as it is the individual’s choice. As such, the successful harm reduction practitioner will help guide an individual toward ever safer behaviors, but will never force abstinence on her/him.
Perhaps the best example of the positive effect of harm reduction services within the homeless population is the Housing First model of permanent supportive housing. The Housing First approach was developed in the early 1990s to address discrepancies between abstinence-only housing services and the realities of individuals experiencing chronic homelessness. As such, it places minimal demands on clients related to substance use and service engagement. Since its development, Housing First programs have been associated with a number of positive outcomes when compared to abstinence-only programs such as higher perceived choice in services among residents, increased access and higher use of behavioral health services, fewer emergency room visits for detox purposes, and reduced involvement in criminal activity. It is because of these and similar outcomes that Housing First is considered an evidence-based practice by the U.S. Department of Housing and Urban Development and the U.S. Substance Abuse and Mental Health Administration.
While harm reduction is only one “ingredient” of Housing First programming, it is one of the most critical to its success. While there are many concerns that harm reduction leads to enabling, it is not an “anything goes model”. Clinicians who employ harm reduction appropriately do not protect their consumers from the natural consequences of their actions, but rather work with them to understand how their behaviors led to those consequences in the first place. (Natural consequences refers to consequences faced by the majority of society, not consequences resulting from arbitrary program rules more often faced by those living in poverty.) In my research, I have seen how harm reduction leads to improved relationships between Housing First staff and residents, which is essential for facilitating positive change. This is because residents are more likely to discuss their substance use openly and seek help related to it when necessary because they do not have to fear being thrown out of their apartments. It is these kinds of open and honest discussions that tools like motivational interviewing and the transtheoretical/stages of change model (tools most substance abuse professionals utilize) hinge on for their success.
If you are interested in learning more about harm reduction and Housing First, I am happy to share copies of my research reports (firstname.lastname@example.org), or you can access helpful information from the following organizations:
This week we suspend our normal blogging topics to pay tribute to a great Housing First champion that we lost last week. Paula Goering was the research lead for Canada’s At Home/Chez Soi pilot project of the Mental Health Commission of Canada, testing Housing First on a national scale. This project, which resulted in over 100 published articles detailing their important findings, convinced the Canadian government to implement Housing First nationwide. It has also provided those of us in the US and other countries with a wealth of research evidence on which to make our own case and inform our practice of Housing First.
We had the pleasure of finally meeting Paula at the most recent Housing First Partners Conference in LA in March. This was quite an honor, and intimidating, as we have read many of her articles and been greatly inspired by her work. We shared a panel on Housing First Fidelity measurement and were both challenged and inspired by Paula’s astute wisdom and commitment to the Housing First model.
We encourage you to take some time to peruse Paula’s significant contributions to the literature on Housing First. Her wisdom and dedication to the Housing First model will not quickly be forgotten.