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.
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:
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.
We saw this story the other day about a shooting at a homeless encampment in Seattle. The initial report is that these people were not targeted because they were homeless. But, it serves as a reminder of the extreme risks people are exposed to when experiencing homelessness. As service providers, we know that survival—in the face of violent episodes like this one or complex health problems—is a constant struggle for many of our participants. The average life expectancy for a person who is homeless is 15 years lower than the average American. Housing is a critical determinant of health. For people experiencing homelessness there is a straightforward solution to alleviate their condition and improve their quality of life, provide housing first. An essential element of that approach is a Low Threshold Admission Policy (LTAP).
In my years of doing street outreach I’ve learned firsthand about the realities that people face when they live on the streets or in shelters. People I tried to help have died while waiting for the housing they so desperately needed. One woman died from her chronic health problems just days before she was approved to move into a housing program. I will always remember the pain of knowing how close she was to having a place of her own. Physical health conditions pose the greatest risk of mortality to people who are homeless, as opposed to substance use disorder or mental illness. However, all of these health conditions are exacerbated by the circumstances of homelessness—the lack of sleep, poor nutrition, difficulty maintaining medications, and exposure to the elements.
Random acts of violence and hate crimes targeting people who are homeless are another reality our participants face. One night, a person I worked with came into the shelter bloodied. He explained that he was attacked on his way there by a group of high-school aged kids. Others have told me stories of being woken up in the night by somebody robbing or assaulting them. The shelters can only provide limited protection since they are frequently overcrowded and underfunded.
But, my experience is not unique. We work with an exceptionally vulnerable population—people who are homeless, oftentimes with co-occurring disorders and limited resources. A tragic fact is that we will lose people we care about in doing this work. It’s not a question of if but when. For those of us that work in homeless services, we know that this is the world that our participants are living in and we hope to be a part of changing it.
The life-threatening risks of homelessness create an urgent need for the Housing First Model and its LTAP for supportive housing programs. LTAP means simplifying our intake processes and removing as many barriers to entry as possible in order to expedite the process of getting people off the streets and into housing. It should not be acceptable to deny a person entry to our programs because of ongoing substance use, untreated mental illness, or criminal background. We must open our doors to people and embrace the idea that housing is a human right.