Embracing Harm Reduction

Many of the people we serve in supportive housing use drugs and alcohol; some in ways that disrupt their lives. That is a fact. Behavior change is hard. That is a truism, and a fact. It is our job as supportive housing providers to serve people who may have struggled for most of their lives with the side effects of poverty, with psychiatric difficulties, adverse effects of drug use and chronic health conditions. It is not our job to ignore that reality, to say “come back when you are ready, we have a home for you when you have overcome your struggles.” For many of us, that has been easier to see when talking about mental or physical health issues, and less clear when thinking about drug and alcohol use.

At the end of the day, they are part of what we signed up for, and as a community with power over access to a scarce resource, it is our job to make harm reduction a standard part of our practice. Overcoming struggles with drugs or alcohol should not be a hoop that people need to jump through in order to have a place to live. The time for controversy is long gone. Harm reduction is a pragmatic response to the reality of the lives of many of the people we serve. The phrase “Housing Works, Shelter Kills,” coined by ACT UP Housing Committee members as they formed Housing Works in 1990, described a fundamental fact about supportive housing – that it is in and of itself a harm reduction strategy.

Despite this, for years many in supportive housing failed to adequately promote and endorse the philosophy of harm reduction and some have even taken an oppositional stand against the idea that harm reduction could be an effective or ethical approach to working with individuals with mental health conditions.

We have made progress since that time, and today while many mental health providers and agencies articulate utilizing a harm reduction approach, the extent to which harm reduction is utilized can vary widely. It is often limited to endorsing the use of motivational interviewing, referring individuals to syringe exchange programs or having safer sex barriers available for tenants. And while a few supportive housing agencies in New York City promote harm reduction as part of their core mission and values, many others are still ambivalent or disinterested.

This is only in part linked to a long-standing belief in abstinence-only based approaches; it is often in some part because of the real challenges that exist when adopting harm reduction policies and practices in a supportive housing environment.

Community Access has a deep understanding of the dilemmas and difficulties of implementing harm reduction because we have been working intentionally for over a decade to improve our harm reduction practices and activities. While we don’t claim to have it all figured out yet, harm reduction continues to inform our work in substantive and meaningful ways. Indeed, it is increasingly inseparable from the other core tenets of our work: self-determination, trauma informed services, healing, recovery and human rights/social justice. We realized some time ago that we cannot simply talk about principles and values if the structures and policies of our agency are working against those same things. So we have worked to ensure our policies are in line with our value of harm reduction.

Just one example of this has to do with our intake process. Utilizing the harm reduction principle of “low-threshold services” we do not put artificial barriers in place for individuals to be able to access our housing. We believe in “Housing First” and so years ago eliminated the concept of “readiness;” instead we work to support individuals to be successful in the housing of their choice. We do not have sobriety/abstinence requirements.

We work to eliminate stigma and discrimination in our day to day work, through our behaviors, language and judgments (e.g. we ask workers to refrain from using words such as “promiscuous”) such that we are not serving up shame with our services. We explore topics such as “what is sex positivity” and then how to “get some” so that we can more effectively engage individuals in conversations about relationships, sexual health and wellness. We seek out and promote concrete harm reduction tools for individuals in our programs, such as safer smoking crack supplies, and even educate ourselves about innovations we don’t currently have in New York, but that exist in other countries, such as Insite, a supervised injection facility in Vancouver, British Columbia. We look forward to the day that this sort of evidence-based intervention might be located here in New York City.

We teach harm reduction in our core trainings with our program staff. This includes understanding motivational interviewing and stages of change as ways to approach and engage individuals. However, we’ve found that these tools, though useful, don’t adequately address the issues of stigma and discrimination faced by individuals who use drugs. So, we also focus attention towards educating each other about how the War on Drugs, Stop and Frisk, racism, classism and heterosexism greatly contribute to the poor health, legal, and economic outcomes for individuals using drugs.

For us, harm reduction is everywhere! Therefore, we practice it in the context of psychiatric drugs, diabetes, self-harm, sex work, hoarding, inter-personal violence and tobacco use to name just a few.

We appreciate that with any movement or culture change, we need some change agents who can guide and support harm reduction work for others. We have a long-standing “Harm Reduction Committee” focused on the work of infusing harm reduction into our agency. It is made up of Harm Reduction Specialists and other individuals with expertise in harm reduction who not only lead agency projects and activities, e.g. promoting Overdose Awareness Month, holding HIV testing days and even hosting parties so both employees and program participants can see that harm reduction can be fun, but also spend regular time on self-education and peer support so as to help sustain themselves in their work in guiding the agency’s harm reduction services. Our Harm Reduction Specialists have amazing creativity and compassion to engage both program participants and staff in the ways that harm reduction can help us all.

We frame our practices and work so as not to be enforcers of house rules, but as support for people to reflect on their experiences, perspectives and goals. We understand that there will always be individuals who use drugs, for a variety of reasons, and believe in responding to the reality of the lives of the people we serve, not some imagined life we might wish them to have or believe they should have. One way our practice reflects this concretely is in a “money management” service – workers helping tenants to create budgets that include planned drug use, as well as rent, food and other critical expenses.

A number of challenges, however, remain. One of the most prevalent involves the tension that exists between the rights of individuals versus the rights of the community in supportive housing. This becomes even more challenging where individuals are sharing rooms in transitional housing and one individual is using drugs while the roommate is trying to abstain. Our approach is to assist individuals who are making complaints to be able to address the behavior(s) of concern themselves (e.g. neighbor to neighbor, or roommate to roommate), help them think through what avenues are available to them as tenants in NYC (e.g. 311, making a complaint to our property management company), help them problem-solve what they themselves can do to protect themselves from the nuisance they are experiencing, give them a space to vent their frustrations and ultimately educate them about what is and what is not possible in housing in NYC. We also work to assist in community building in our housing, so that over time social norms in buildings are created through the tenants themselves.

We also find it difficult to keep as connected as we would like to the important harm reduction advocacy that happens in the world of substance use services, as our systems are still so “siloed.” For example, when we attend mental health events and conferences, there is often no mention of harm reduction issues at all. We are still working to build relationships with harm reduction organizations for support and collaboration to help us improve our practice and policy work.

With the changes occurring in our healthcare system, we at Community Access are eager to continue growing and pushing harm reduction to have a greater role in the mental health and supportive housing community. Our future as effective service providers depends upon open doors, policies that do not discriminate against the people we exist to serve and a field that embraces the challenges of that reality.

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