We’ve taken a break from blogging the past month to work on our annual conference, Harm Reduction in the House. The conference focuses on how harm reduction can be applied to improve the delivery of housing and other social services. There are a number of nuanced issues that come up for participants in programs using the Housing First Model. This year, conference attendees were able to hone in on areas to use harm reduction including safer substance use practices, sexual health promotion with tools like PrEP, and engagement strategies that promote positive changes like the SODAS Method. The conference hosted several hundred presenters and attendees from around the Midwest including Illinois, Indiana, Wisconsin, Michigan, and Ohio. In this post, we look at some of the reaction and takeaways from the conference.
The theme of this year’s conference was “Growing from Our Roots.” Harm reduction is getting into the mainstream. In recent years, a broader range of programs and providers around the world have embraced harm reduction. Growing from Our Roots is a reminder that harm reduction work began with drug users and people actually engaged in risky behaviors. Their community, respect, and self-determination drive the principles of the harm reduction philosophy in service delivery. They are experts in their own lives and must be included in the work and accompanying advocacy efforts. Daniel Raymond, policy director at the Harm Reduction Coalition, attended the conference and offers additional thoughts on this topic and more in “Holding space for the unredeemed: harm reduction and justice.”
One of the popular sessions at the conference was the “Irreverent: Harm Reduction Youth Work and Radical Ministry” workshop. Rabbi Menachem Cohen and Pastor Alli Baker led a group discussion including youth who are LGBTQ and have experienced homelessness. The conversation explored the experience of homelessness from a young person’s perspective and what providers can do to create safe, welcoming environments. When workers listen nonjudgmentally and remain flexible, they have the power to support youth in getting off the streets and remaining housed. Rev. Kathryn Ray is a member of Clergy for a New Drug Policy and offered her thoughts on this workshop after attending the conference in “Rule Breaking and Radical Love.” She discusses the way that harm reduction can open doors for people and says, “Harm reduction work is gospel work.”
We have to acknowledge that we could not put on this conference without the help of our amazing volunteers. Thanks to everyone who pitched in! Among other duties, we had volunteers live-tweeting the conference. Below are some of the highlights from the day. For a full list of tweets, check out #HousingisHR on Twitter.
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.
"...Then things started to change. I started working real close with them, being honest with them."
We want to take a moment to acknowledge the great story that The Indianapolis Star wrote about Penn Place, a first-of-its-kind Housing First program in Indianapolis, IN. This article is an excellent example of how we can be public advocates for our programs and the people that we serve. Penn Place also used this opportunity to ask for donations from the community and received resources to support their participants. Educating our communities about the Housing First Model and its benefits can improve the public support of programs like Penn Place. But, it’s not enough. We have to remember to continue educating the participants in our programs about the Housing First Model as well.
Think about the mindset of a person entering a Housing First program from homelessness. Their days are dictated by survival—wondering where their next meal is coming from, where they can sleep, what dangers might await them if they manage to close their eyes for a few hours. Without a sense of safety, they are under constant stress and it is difficult to focus, think logically, and connect with other people. An opportunity to escape the constant struggle of homelessness is presented and they jump at it! When you’re offered housing, there’s no space to consider the benefits of reduced service requirements and a client-centered approach. That means what we tell someone at intake or orientation about the Housing First Model might not be absorbed. So, we should seek other opportunities to reinforce our approach and why we use it.
There are aspects of the Housing First philosophy that are expressed in our daily work with clients. Any time we collaboratively help someone explore potential solutions to their problems, we highlight the Housing First emphasis on flexibility in services and valuing their perspective. In addition, we should explicitly describe aspects of the Housing First Model or they may go unnoticed. As one Housing First program participant explained, “It was shortly after that in one of our one-on-one sessions where [my case manager] said…’You realize your housing is not contingent on you being abstinent?’ And I hadn’t realized that at that point…Then things started to change. I started working real close with them, being honest with them.” All the flexibility and support in the world doesn’t make a difference if people don’t know it’s there. Even if we explain upfront that abstinence from substance use is not required, our clients are conditioned to assume that service providers have certain expectations. That’s why it’s so important that we revisit the Housing First Model with our participants and discuss the meaning of harm reduction and our commitment to deliver services that they want. Continually educating participants about Housing First can help us develop trusting relationships.
As helpers, our lives can get hectic. It’s easy to get caught up in managing our caseload and the day-to-day needs of our clients. But, it’s important to find opportunities to reinforce the approach to housing used in our programs. The Penn Place article itself is another opportunity to revisit the Housing First Model with our participants. It could be shared with them in a home visit or a community meeting. Finding ways to help participants understand our programs ensures that they get the most out of them. We should engage our participants about Housing First—what it is, what makes it different, and how it can benefit them.