When to Broach the Subject: Exploring How Case Managers Implement Harm Reduction

Background: Housing First is an evidence based practice serving homeless people with co-occurring disorders. The program provides people with immediate access to independent housing not contingent on treatment adherence or sobriety and takes a harm reduction approach to substance use. Harm reduction is defined as decreasing the adverse effects of drug use while a person is actively using (Single, 1995). Although harm reduction is now more accepted as a clinical strategy, relatively little is known about how it informs frontline practice. This qualitative study explores how Housing First case managers implement harm reduction, focusing on when and how they approach substance use among consumers.

Methods: Using ethnographic methods, researchers followed 10 consumers and 14 case managers from two treatment teams in a Housing First program, over the course of a year. Researchers observed service contacts in the program office, the community and consumers' homes. Field notes were recorded on the social interaction between case managers and consumers. In-depth semi-structured interviews were also conducted with study participants. Data analysis was based on grounded theory (Glaser & Strauss, 1967), using open coding to identify emergent themes related to harm reduction. Higher order codes were then developed to inform a theoretical framework for decision making around substance use.

Results: The analysis revealed how communication between case managers and consumers regarding substance use interacted with the consumer-provider relationship. The quality of the relationship both affected and was affected by the ways in which consumers and case managers broached the subject of substance use. The following patterns of communication regarding substance use emerged: 1) the consumer being first to directly acknowledge active use, 2) the case manager being first to talk directly with the consumer about use, or 3) both the case manager and consumer avoiding direct communication about use. Within these communication patterns the following themes were identified: honoring self-determination, recognizing small steps, taking a nonjudgmental stance, and offering a “safe space”.

Conclusions and Implications: This study provides valuable insight into how harm reduction is implemented in clinical practice. The qualitative findings illustrate the complexity of addressing substance use and the extent to which communication about use is shaped by the quality of relationships between consumers and providers. As harm reduction becomes more widely adopted, evidence about the social processes involved in implementation is important to understand how the model translates to other settings.