Research That Matters (January 17 - 20, 2008)

Purpose: This study examines the perceptions of the harm reduction (HR) model of practice from the dual perspectives of residents and mental health workers in a community-based housing program serving people with long histories of mental illness, substance use, and homelessness. Individuals suffering from co-occurring disorders have historically been difficult to engage and retain in treatment programs that make service contingent on abstinence from alcohol and other drugs (Carey, 1996). HR approaches focus on reducing the harm users do to themselves and society and represent a way to engage and retain individuals with dual disorders in treatment (Denning, 2001; Marlatt, 1996). The HR program in this study does not make housing or other services contingent on abstinence and provides motivational and supportive services to residents that focus on reducing harmful behaviors. The practice of HR is controversial because it requires practitioners to accept their clients' substance use and views abstinence as merely one outcome at the end of a much larger continuum of broader outcomes. This can result in ethical conflicts for staff and practical concerns for clients (Brocato & Wagner, 2003; MacMaster, 2004; MacCoun, 1998).

Methods: In-depth semi-structured interviews were conducted with 20 racially and ethnically diverse male and female adult residents of a program serving individuals diagnosed with substance-use and serious psychiatric disorders and 20 mental health workers (predominantly white) providing comprehensive community mental health services to residents in the same program. Interview transcripts were analyzed using a grounded theory approach (Glaser and Strauss, 1967). At least two individuals coded each interview using an open coding process. Analyses were conducted to identify common categories and themes within and across each case. A matrix of common categories was then merged into broader themes using a cross-comparison approach (Miles & Huberman, 1994).

Results: Interviews produced descriptive data on how residents and workers perceived the HR approaches practiced at the program. Themes that emerged from the interviews included: a) HR enhanced relationships between staff and workers; b) HR was a pragmatic alternative to abstinence-only approaches; c) HR approaches helped residents realize that they wanted to stop their use; d) HR enabled some residents to continue their destructive behaviors; e) workers felt they were participating in their clients' self-destructive behavior by shielding them from the natural consequences of their actions; f) residents complained that uncontrolled use in the program was detrimental to those trying to make healthier changes; and g) the ambiguity and controversial nature of the HR model led to conflicts among workers at the program.

Implications and Conclusions: This study provides an authentic description of some of the opportunities and challenges harm reduction offers from the real-world perspective of workers and clients. This study demonstrates the complexities associated with this approach and the skills and supports necessary for the successful implementation of harm reduction approaches into community-based mental health settings. This study also provides critical information regarding the training, recruitment and supervision of workers who are or will be practicing harm reduction in community mental health settings.