Harm Reduction

While the lack of affordable housing and poverty remain the primary causes of homelessness among Americans, diagnoses of severe mental illness and substance abuse or addiction can act as double locks on an already closed door. For a substantial number of the homeless, these conditions create an almost impenetrable barrier to housing and strand these individuals in the most remote margins of society. To gain access to housing for the dual-diagnosed homeless, “consumers” are almost invariably required to abstain completely from using alcohol or street drugs and participate in psychiatric treatment. In addition, because most housing programs insist on the twelve-step abstinence mode or other sobriety-contingent models as a condition for remaining in housing, formerly homeless people with histories of substance abuse are at great risk of repeated housing loss and long periods of homelessness. Pervasive sobriety and treatment requirements, despite well-researched evidence of the barriers they pose to the dual diagnosed (Coalition for the Homeless, 1999; Rowe et al., 1996; Interagency Council on the Homeless, 1992), prevent the most persistently homeless individuals from obtaining housing; moreover, such requirement often hinder them from retaining housing when they relapse.

One of the major dilemmas surrounding abstinence/treatment-contingent housing, also known as “linear residential continuum of care” programs, is that while concurrent mental illness and substance abuse increase one's risk of becoming homeless (Goldfinger et al., 1999), homelessness and residential instability exacerbate addiction (Coalition for the Homeless, 1999; Interagency Council on the Homeless, 1992). Such a situation often confronts the dualdiagnosed homeless person who lives in treatmentcontingent housing. Treatment for substance abuse and mental health is typically provided by different providers and, in many cases, by different agencies. A client making an earnest effort to comply with his or her twelve-step treatment programs is told to abstain completely from all alcohol and conscious-altering drugs. However, the same individual may also have a comorbid mental illness and need to comply when a treating psychiatrist prescribes consciousness-altering medications for psychiatric symptoms. And if such persons are living in treatment-contingent housing and, as often happens, begin to relapse, they cannot discuss drug problems or emerging psychoses with a housing counselor, for fear of eviction. Residential instability is also a risk factor for a number of other conditions that inhibit recovery, including physical illness, social dysfunction and isolation, joblessness, poverty, criminal involvement, and criminal punishment (McQuistion et al., 2003, Rossi et al., 1987). Thus, people with dual diagnoses remain “system misfits” because of the frustrating and contradictory [Page 190]expectations and requirements that could be easily remedied by using an integrated approach to treatment and services (Mueser, Noordsy, Drake, & Fox, 2003; George & Krystal, 2000) that incorporates a harm reduction approach (Tsemberis & Asmussen, 1999).

Harm reduction provides a pragmatic, effective, and compassionate approach that can be used to address the problem of treatment and housing for individuals who are homeless, substance abusing, and mentally ill. Harm reduction is a public health alternative to the moral, criminal, and disease models of drug use and addiction (Marlatt, 1998). It seeks to engage and stabilize the addict and then work to address the factors that contribute to the addiction. In fact, the harm reduction strategy is already being effectively employed in a number of similar contexts. Two recent examples are needle exchange and jail diversion programs, which have successfully mitigated needle-related infectious disease transmission (Langendam, van Brussel, Coutinho, & van Ameijden, 2001) and reduced the psychological, economic, and socially hazardous conditions experienced during incarceration (Klein, 1997).

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