Provider views of harm reduction versus abstinence policies within homeless services for dually diagnosed adults
Open accessAbstract
Harm reduction is considered by many to be a legitimate alternative to abstinence-based services for dually diagnosed individuals, yet there is limited understanding of how varying approaches affect front-line practice within services for homeless adults. This paper examines how front-line providers working with individuals who have experienced homelessness, serious mental illness, and addiction view policies of harm reduction versus abstinence within two different approaches to homeless services: the traditional or "treatment first" approach that requires abstinence, and the more recent housing first approach that incorporates harm reduction. As part of a federally funded qualitative study, 129 in-depth interviews conducted with 41 providers were thematically analyzed to understand how providers view harm reduction versus abstinence approaches. Themes included the following: (a) harm reduction as a welcomed alternative, (b) working with ambiguity, and (c) accommodating abstinence. Drawing on recovery principles, the authors consider the broader implications of the findings for behavioral health care with this population.
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Harm reduction allowed service providers to have flexibility in their roles, as they were not required to enforce rules related to abstinence from substance use like providers of continuum-based housing programs.
“Harm reduction allowed service providers to have flexibility in their roles, as they were not required to enforce rules related to abstinence from substance use like providers of continuumbased housing programs (Andvig et al., 2018; Henwood et al., 2014).”
From Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review (2021) · cites this paper as Henwood et al., 2014
HF providers reported that a harm reduction approach allowed tenants to be more open about their substance use and stay engaged in services.
“HF providers reported that a harm reduction approach allowed tenants to be more open about their substance use and stay engaged in services”
From Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review (2021) · cites this paper as Henwood et al. (2014)
The flexibility also posed challenges for service providers, such as determining when to intervene and producing ambiguity about whether or not they were 'doing enough' to support tenants.
“Yet, the flexibility also posed challenges for service providers, such as determining when to intervene and producing ambiguity about whether or not they were 'doing enough' to support tenants (Henwood et al., 2013, 2014; Tiderington et al., 2013).”
From Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review (2021) · cites this paper as Henwood et al., 2014
Harm reduction involved supporting tenants to make 'difficult choices,' such as drawing boundaries in response to an apartment takeover.
“Harm reduction involved supporting tenants to make 'difficult choices,' such as drawing boundaries in response to an apartment takeover”
From Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review (2021) · cites this paper as Henwood et al. (2014)
TF providers evoked discretionary power when enforcing consequences and rules, yielding ambiguity.
“TF providers also evoked discretionary power when enforcing consequences and rules, yielding ambiguity”
From Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review (2021) · cites this paper as Henwood et al. (2014)
HF providers experienced more ambiguity in their work than TF providers.
“HF providers experienced more ambiguity in their work than TF providers”
From Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review (2021) · cites this paper as Henwood et al. (2014)
Harm reduction policies made service providers' jobs less stressful, as they did not continually have to reinforce abstinence.
“Harm reduction policies made service providers' jobs less stressful, as they did not continually have to reinforce abstinence”
From Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review (2021) · cites this paper as Henwood et al. (2014)
Harm reduction could yield insecurity that providers were 'not doing enough' (p. 85).
“harm reduction could also yield insecurity that providers were 'not doing enough' (p. 85)”
From Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review (2021) · cites this paper as Henwood et al. (2014)
Abstinence can be accommodated within a harm reduction framework.
“Abstinence can be accommodated within a harm reduction framework”
From Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review (2021) · cites this paper as Henwood et al. (2014)
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Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review
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- Authors
- Henwood, B. F., Padgett, D. K., & Tiderington, E.
- Affiliations
- University of Southern California (US)
- New York University (US)
- Corresponding author
- Henwood, Benjamin F.
- Venue
- The Journal of Behavioral Health Services & Research
- Published
- 2013-02-13
- Volume
- 41
- Issue
- 1
- Pages
- 80-89
- ISSN
- 1094-3412 (ISSN-L)
- 1556-3308
- PMC
- PMC3675178
- OpenAlex
- W2006217459
- Cited by
- 46
- References
- 38
- Citations by year
- 2026: 3 · 2025: 8 · 2024: 4 · 2023: 1 · 2022: 2 · 2021: 6 · 2020: 6 · 2019: 4 · 2018: 3 · 2017: 2 · 2016: 4 · 2015: 3
- FWCI
- 4.23
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Licence
- www.springer.com/tdm (tdm)
- Locations
- The Journal of Behavioral Health Services & Research (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Rutgers University Community Repository (Rutgers University) (acceptedVersion)
- Rutgers University Community Repository (Rutgers University)
- Funders
- U.S. Public Health Service (R01-69865)
- National Institute of Mental Health (R01MH069865, R01MH084903, F31MH083372)
- Topics
- Health Sciences › Health Professions › General Health Professions › Homelessness and Social Issues
- Health Sciences › Medicine › Epidemiology › HIV, Drug Use, Sexual Risk
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Keywords
- harm reduction, abstinence-based treatment, homelessness services, Housing First, severe mental illness, addiction, provider perspectives, recovery principles, behavioral health services
- MeSH terms
- Adult, Attitude of Health Personnel, Mental Disorders, Female, Ill-Housed Persons, Housing, Humans, Interviews as Topic, Longitudinal Studies, Male, New York, Diagnosis, Dual (Psychiatry), Substance-Related Disorders, Qualitative Research, Harm Reduction, Community-Based Participatory Research
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