"I Don't Think of It As a Shelter. I Say I'm Going Home: A Program Evaluation of a Low Threshold Shelter for Women Who Use Drugs

Background & Purpose: Unsheltered homelessness is an increasingly pressing problem in cities throughout the United States, with the number of persons experiencing unsheltered

homelessness nationwide increasing by roughly 20% between 2010 and 2022. The growth of large encampments is particularly concerning. Unfortunately, the dearth of evidence about how best to assist encampment residents leads cities to enact improvised, potentially harmful responses. In winter 2021, the City of Boston planned a response to several large encampments that had expanded during 2020- 2021. The city’s plan involved: 1) scheduling a sweep (i.e., eradication of encampments); and 2) providing low-threshold shelters—which operate under a human rights-based model as an alternative to traditional shelters—for individuals living in encampments. The purpose of this study was to evaluate one of the new low-threshold shelters designed specifically for women who used drugs. The two primary aims were: 1) to examine guests’ beliefs about shelter policies; and 2) to understand the staffs’ experiences working in a low-threshold shelter.

Methods: We conducted semi-structured interviews with 16 women living in the shelter and ten staff during the summer 2022. We asked guests about why they decided to stay at this shelter, their perspectives on shelter policies, and their relationships with other guests and staff. Staff were interviewed about their perspectives on shelter policies and harm reduction and their relationships with the guests. Interviews were thematically analyzed.

Results: Themes in guest interviews included: autonomy and dignity; safety; relationships with staff; and non-judgmental environment. Guests reported the ability to come and go as they wanted, the option to stay inside during the day, and having an assigned bed, among other elements, promoted their autonomy and dignity. Freedom to make decisions about their time, developing meaningful connections with staff, and time away from the open-air drug market promoted safety and dignity. Most guests reported the non-judgmental environment, including staffs’ attitudes toward their drug use, made them feel respected; however, others believed the shelter’s lack of structure and regulations hindered personal growth. All guests reported their experience in this shelter were better than in any previous shelter.

Themes in staff interviews included: pragmatic shelter policies; perspectives about harm reduction; passion for their work; and relationships with guests. The co-directors and staff designed the shelter quickly, turning to international literature, local harm reductionists, and women living in encampments for guidance. Staff appreciated the value of low-threshold shelters considering the dual crises of housing and opioid overdoses; however, some staff expressed discontent with the model, believing it enabled drug use and discouraged guests from “getting better.” Guest specialists, nurses, and security staff all described strong commitment to guests’ health and stability, echoing guests’ sentiments about their positive relationships.

Conclusions: This evaluation begins to fill the gap in literature about opening and operating low-threshold harm reduction shelters. It demonstrates the critical importance of policies that prioritize immediate needs and safety and hiring staff committed to a positive, welcoming environment. Cities should explore how low-threshold shelters can serve as an alternative to traditional shelters and encampments.