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: