Bridging Disciplinary Boundaries (January 11 - 14, 2007)

Study Purpose: Individuals suffering from co-occurring substance abuse and serious mental illness and who experience chronic homelessness have historically been difficult to engage and retain in residential treatment programs that require abstinence as a prerequisite to continued service. The integration of a harm reduction approach into residential treatment programs that does not make housing contingent upon abstinence represents a way to engage and retain individuals with dual disorders in treatment.

This mixed method process evaluation explored staff and client perceptions regarding the use of the harm reduction approach and evaluated first and second year outcomes of a 18 unit housing program serving people with a long history of mental illness, substance abuse problems, and homelessness. This innovative program provides support and clinical services and uses a harm reduction approach that does not require residents be abstinent to stay in the program.

Methods:

1. Surveys and six qualitative focus group interviews with clinical and supervisory staff (N=37) explored their perceptions of the harm reduction approach two months prior to program implementation.

2. Clinical outcomes for program residents (N=21) included housing stability, arrest/rearrest data; hospitalization rates and employment status. First and second year clinical outcomes were compared with outcomes for residents in the year prior to entering the program.

3.A total of four qualitative focus group interviews were conducted with program residents at 3 months (N=10) and 12 months (N=10) regarding the strengths, weaknesses and overall satisfaction with the program.

Results:

1.Practitioners indicated that using the harm reduction approach helped them engage clients and was a pragmatic alternative to abstinence-based approaches Some were frustrated by the perceived ambiguity of the approach regarding long-term outcomes and client expectations and had difficulty negotiating the tolerance for drug and alcohol use required of the approach.

2.Clinical outcome data showed increases in stable housing rates and modest declines in psychiatric hospitalization. Employment and arrest outcomes were inconclusive mainly due to small sample size. Retention rates were very encouraging with only three drop-outs in the first two years of the program -- two at 9 months and one at 9.5 months.

3.Focus groups with residents showed that they were very pleased with their relationships with staff, living conditions and the safety the program. Tension points centered on the issue of abstinence and the impact other residents' drinking or drug-related behaviors had on their recoveries. Responses also indicated an increased amount of mutual aid and social support generated among residents leading to enhanced self-worth and commitment to recovery-related goals.

Implications: This study suggests that a harm reduction approach may be a useful mechanism for retaining traditionally hard to serve populations in treatment. Results also indicate that harm reduction may be inappropriate for some individuals unable or unwilling to considering reducing their alcohol and substance use. While many were receptive to this approach, the ambiguities and contradictions voiced by some clinical staff have important training and supervisory implications for social service administrators considering the harm reduction approach.