1. Harm Reduction in HousingH.O.M.E. ConferenceSeptember 16, 2010 Christy Respress, MSW Pathways to Housing DC 1

2. Pathways to Housing DC: Who we Serve Persons experiencing serious mental illnesses such as schizophrenia, bipolar disorder, and major depression Experiencing chronic/long term homelessness Co-occurring substance use disorders- at least 80% Serious medical issues Histories of trauma and violence Lack of hope Various stages of readiness to make change, with the majority entering in precontemplation or ambivalence 2

3. Pathways DC Program and Housing Services 4 Assertive Community Treatment (ACT) teams with the capacity to serve 300 individuals. Each participant on the ACT team receives their own scattered site apartment. PSH program serving 135 people w/ intensive case management and scattered site apartments Outreach Team Community Support- 40 served Supported Employment Program 3

4. Housing First Program Practice Immediate access to permanent, independent housing No requirement for sobriety or treatment Harm reduction approach to services Program participant sets service priorities (e.g., job, family connection, addictions Tx, psychiatric Tx, etc.) Follow standard lease obligations Need to visit in home at least 1x per month 4

5. Practitioner anxiety around allowing people to make choices in PSH Health issues Alcohol/Drug use Psychiatric medications

7. Recovery is a process and looks different for each person

8. People still need support while they’re using!

9. Need a framework for delivering services while person engaging in harmful activities/behaviors, actively using drugs/alcohol, or disengaged from psychiatric/medical treatment- harm reduction6

10. Recovery: Implications for PSH Staff Deegan: The Dignity of Risk, The Right to Failure “Chronically normal people’ are allowed to make dumb, uninsightful decisions all the time in their lives…. We must be careful to distinguish between a person making (from our perspective) a dumb or self-defeating choice, and a person who is truly at risk. Just as Elizabeth Taylor has failed her 8th marriage and not a single case manager has jumped in to control her "marriage impulse", so too do people with psychiatric disabilities claim the right to make mistakes, to learn through failures and to take risks. The reclaiming of these rights is referred to as the dignity of risk and the right to failure.”

11. Abstinence as a requirement for permanent housing Most programs mandate abstinence from drugs and alcohol to obtain/maintain housing. Most also mandate psychiatric treatment. Some people can achieve this, but many others (especially those who are dually diagnosed) remain homeless.

12. Problems with Abstinence Model:The Abstinence Violation Effect Each failure of the addict to achieve the goal of abstinence leads to a negative adjustment of self-opinion in tune with the failure just experienced. This negative readjustment of self opinion may feed on itself, lowering self-esteem and diminishing the belief and hope in the possibility of making changes on one’s own.

13. Harm Reduction Practice and the Abstinence Violation Effect (AVE) Harm reduction avoids the downward spiral of AVE, by focusing on helping clients take small steps forward and maintain a positive attitude and direction, while rewarding each small step along the way. “Even though some people can stop just like that,” opined one person who was a heavy drinker, snapping his fingers. “I couldn’t stop like that. I thought it was good when I went from a 40-ouncer to a 12-ouncer.”

14. Harm Reduction: What is it? Harm reduction is a progressive alternative to the prohibition of some potentially dangerous lifestyle choices, e.g., smoking, drug use, alcohol use, casual sex. The central idea is to recognize that some people have, and will, engage in risky behaviors. The main objective of harm reduction is to mitigate the potential dangers and health risks associated with the risky behaviors themselves.

15. Definitions of Harm Reduction 12 Harm reduction is a set of practical strategies that reduce negative consequences of drug use, incorporating a spectrum of strategies from safer use, to managed use to abstinence. Harm reduction strategies meet drug users "where they're at," addressing conditions of use along with the use itself. (Harm Reduction Coalition) Harm Reduction is a set of non-judgmental strategies and approaches which aim to provide and/or enhance skills, knowledge, resources and support that people need to live safer, healthier lives. (Streetworks, 1997).

16. The Principles of Harm Reduction Harm reduction is any action that attempts to reduce the harm of drug abuse and drug prohibition. There can be no punitive sanctions for what a person puts in their body or refuses to put in their body. People use drugs for reasons and not all drug use is abuse. People can, and do, make rational decisions about important life issues while still using. Denial is not actually denial. It is a product of shame and punitive sanctions and is usually quite conscious.

17. Principles of Harm Reduction, cont’d Ambivalence and resistance to change are “human”. It is our job to work with someone’s ambivalence, explore it, not confront it. Addiction is a relationship, an attachment that offers significant support to the person. Treatment must offer that support, as well as respect that maybe we can’t do it as well or with such reliability. Success is any positive change- no matter how big or small.

18. Does Harm Reduction mean that abstinence is never a goal? Abstinence is the ideal goal for persons using illegal drugs. Ambivalence towards change is a common factor in drug use/abuse. When abstinence is mandated by housing and treatment programs, many people will just avoid services completely. Even if a person is not ready for addiction treatment, they may be open to other health interventions- including housing!

20. Principles of harm reduction support Stages of Change- Prochaska & DiClemente

21. Most needed in early stages of precontemplation and contemplation

23. Housing First andHarm Reduction Risk reduction: Housing first programs decrease the likelihood of drug overdose, dealing, incarceration, impoverishment, malnourishment, unending homelessness, ill health, spending on drugs and alcohol and other conditions that would otherwise befall a person who must achieve abstinence in order to be housed.

24. Housing First and Harm Reduction Practice Support: Once housed, the program staff offer services and support that include an acceptance and tolerance of symptoms, use, and relapse while the individual remains housed.

25. Housing First and Harm Reduction Practice Relapse: Clients typically move from stage to stage at their own pace, but when they stop moving or move backwards they are still accepted and supported. is an expected and natural step in the long course of recovery, and clients are able, indeed encouraged, to discuss their psychoses and addictions with staff in an open and accepting manner.

26. Harm Reduction Practice Candid conversation: Once a client is engaged in a therapeutic relationship and there is a candid discussion concerning the symptoms of mental illness or drug and alcohol use, the stressors leading to these conditions are addressed. With this, the process of recovery begins.

27. What Does Harm Reduction look like at PTHDC? 22 Addictions Psychiatric Medical

28. Understanding the Process of ChangeProchaska & DiClemente Precontemplation Contemplation Preparation Action Maintenance Relapse

29. Precontemplation…notseriouslyconsidering change There is little or no consideration of change in the foreseeable future. Ex: “I don’t have a problem- you’re my problem!” Tasks: Increase awareness of need for change and concern about the current pattern of behavior; envision possibility of change. Goal: Serious consideration of change for this behavior.

30. Engaging the “Unmotivated” PersonP. Deegan: Action Steps to Use With People in the Precontemplation Stage Getting the person to move into action is not the goal at this stage. During this stage develop your relationship with the client. Join with the client. Begin to understand what they are motivated toward and what they are motivated against. Don't nag, but don't ignore the problem as you see it. Remember, for the client in this stage there is no problem. Focus on consciousness raising, i.e., help the person see the problem, the relationship between their behavior and its consequences, see how others are affected by the problem, and see how others have dealt with the problem. Directly and frequently offer alternative activities/options. Sometimes people move out of this stage spontaneously due to life events & developmental milestones such as one's 40th birthday, siblings have all married, high school reunion, death of a loved one, Create opportunities for getting more information about the problem.

31. Engagementand Motivation Deegan: Reframing the Question of Motivation Less Helpful Questions: How can I motivate Jim? How do I get Jim to do what I want him to do? (this sets up a power struggle) Question of Motivation Reframed: What is going on with Jim such that he is not more involved in improving the quality of his life?

32. Contemplation…thinking about change The stage where the person examines their patterns of behavior and the potential for change in a risk-reward analysis. Ex: “I know that smoking crack only gets me into trouble and makes me do bad things, but I’ve tried to stop before and I always start using again. I don’t think I can do it”. Tasks: Analysis of the pros and cons of the current behavior and the costs and benefits of change. Goal: A considered evaluation that leads to a decision to change.

33. Decisional Balance exercise (see handout)

34. Preparation…getting ready to make a change. The stage where the person makes a commitment to take action to change the behavior pattern and develops a plan and strategy for change. Ex: “I want to go to detox before moving into my new apartment so that I have a clean start”. Tasks: Increasing commitment and creating a change plan that is acceptable, accessible, and effective. Goal: An action plan to be completed in the near term.

35. Action…making the change The stage in which the individual implements the plan and takes steps to change the current behavior pattern and to begin creating a new behavior pattern. Ex: “I’ve been clean for 3 weeks! I’ve got a sponsor and have been going to meetings every night. I feel so good!” Tasks: Implementing strategies for change; revising plan as needed; sustaining change in face of difficulties. Goal: Successful action to change current pattern. New pattern established for a significant period of time (3-6 months)

36. Maintenance…sustainingbehavior until itis integrated into lifestyle The stage where the new behavior pattern in sustained for an extended period of time and is consolidated into the lifestyle of the individual. Ex: “I went back to my old neighborhood after school last week and I didn’t have any desire to use. Actually, it made me sad that so many of my old friends were doing the same old things when I’ve moved on.” Tasks: Sustaining change over time and across a wide range of situations. Avoiding slips and relapse into old patterns of behavior. Goal: Long term sustained change of the old pattern and establishment of a new pattern of behavior.

37. Relapse…slipping and recycling back toprevious behaviors The stage where a person has re-engaged in the previous behavior to a significant degree. The can re-enter at any stage of contemplation to address the relapse from pre-contemplation to action. Ex: “I used my rent money to buy crack. I’ve been clean for a year- I knew I would mess up. I don’t know if I can do this again.” The person may feel like a failure and be discouraged about their ability to change. Normalize that this is often part of the process, reflect on past successes, make a plan for recovery.

38. Practicing harm reduction allows us to continue to provide high quality, compassionate services to people still engaged in harmful behaviors. This model doesn’t discriminate against persons with disease of addiction. Who needs to change? We do. Requires most staff members to approach the work in a new way. 33

39. Contact Info Christy Respress, MSW (202) 529-2972crespress@pathwaysdc.orgwww.pathwaystohousing.org 34