The harm reduction approach to shelter management

In Bethesda Project’s Church Shelter Program (CSP) for chronically homeless men, we do not require drug treatment, drug testing, or sobriety to enter or remain in shelter.

As a case manager for the CSP, I work with men who have a range of experiences with drugs and alcohol (which I’ll refer to simply as “drugs”). This includes men who have never used drugs, men with significant periods of sobriety, and men working towards sobriety. It also includes men who use drugs and who don’t want to stop using them; men for whom all existing drug treatment interventions have failed; men who have consumed drugs for so long, and to such a strong degree, that they do not consider sobriety a viable option for themselves; and men who actually require medical attention if they do not consume their substance of choice within a certain period of time.

It includes men who manage their substance use well enough that no one notices it. It also includes those who consume to the point of psychosis, belligerence, and police intervention.

This stuff is gnarly. But that doesn’t mean there’s nothing we can do.

In the CSP, we respond to these scenarios with a philosophy and set of practices known as harm reduction. It involves accepting a person’s substance use non-judgmentally and matter-of-factly, then working with the person to reduce the harms they may experience as a result of substance use.

We recognize that all substance use contains some level of risk and we know we cannot protect people from all harm. However, we also recognize that people are free to make their own choices — and we want those choices to be informed and free of unnecessary or preventable harm. When we approach people from this angle, we support their well-being and earn their trust — both of which are necessary in order to meaningfully talk with them about drug treatment and recovery.

We realized that our commitment to harm reduction needed to extend beyond the context of an individual’s substance use.

In emergency shelter, harm reduction can look like many things. For example: providing lip balm to a person who has blisters from smoking crack-cocaine; encouraging a person with an alcohol use disorder to take his psychiatric medication with one beer instead of five; or talking with a person who injects heroin about how snorting heroin could lower his risk of overdose and infection.

Sometimes harm reduction is an intentional step supports towards sobriety; other times, it helps a person adjust their substance use to a level that is safer and more manageable, but without sobriety being the goal. For some people, quality of life involves some substance use; for others, it doesn’t.

Ultimately, that’s not for me to decide. Our goal is to keep you alive long enough to resolve your housing crisis — then, after you have the stability that housing provides, you can respond to your substance use in the way that feels right for you.

At a certain point, we realized that our commitment to harm reduction needed to extend beyond the context of an individual’s substance use. This realization occurred after a shelter guest (who I’ll call “Mark”) violated the shelter code of conduct by consuming heroin in the bathroom one evening. He was found semi-conscious by two other guests, who immediately alerted staff and worked to revive him. The staff-member called paramedics, but before they arrived Mark had left the shelter on his own.

In debriefing about the incident the following morning, we realized that — technically — because Mark had violated the code of conduct, he should be discharged from the shelter. We also realized that if Mark returned to living on the streets, his risk of overdose would likely increase — which meant that our management decision, though technically appropriate, would have increased his risk of harm. Yet we also realized that his behavior had scared the other shelter guests, and in that sense had harmed them.

With that in mind, we called a meeting with the other shelter guests to conduct a temperature check of the community. We asked the guests a range of questions: How are you feeling about what happened? How are you feeling about Mark right now? How would you feel if he came back here? What kind of response from staff do you think would be fair in this situation?

What we learned surprised us. The other guests in the shelter unanimously agreed that Mark should be welcomed back to the shelter immediately. They acknowledged their own struggles with sobriety and agreed that Mark should not be punished for struggling to manage his substance use. As a result of this meeting, Mark was located and readmitted to the shelter the following day and warmly received by his peers. These same peers then made themselves available to Mark as recovery supports to encourage safer substance use and treatment options.

This experience represented the beginning of ongoing efforts to extend the philosophy of harm reduction and apply it to our management decisions — particularly when it comes to disciplinary action. In this context, harm reduction doesn’t mean “no consequences.” Instead, it means loosening our reliance on punishment, the threat of punishment, and the fear of punishment as our only tools for seeking justice. Above all, it means that we seek to respond to harm and wrongdoing without causing more harm in the process.

For example, recently shelter staff were informed about a guest (who I’ll call “Leo”), with serious untreated mental illness, who was making significant noise disturbances overnight. According to the shelter code of conduct, repeated and intentional sleep disturbances could result in discharge from the shelter. In thinking about a harm reduction approach to management, we reframed this incident as a matter of “How can we restore calm in the community?” rather than “What rule was broken, who broke it, and how should he be punished?”

We seek to respond to harm and wrongdoing without causing more harm in the process.

This approach led us to hold a community meeting with the other shelter guests to discuss the problematic behavior, how they felt about it, and what could be done about it (Leo was not present for this meeting). At first, the guests vented about the situation. Then I reflected back to them: “I hear many of you saying you feel uncomfortable with Leo, but do you feel unsafe with him here?”

After considering the question, the guests all agreed that they did not feel unsafe with Leo, but they did feel extremely annoyed by him. Some suggested that Leo should still be discharged to the street.
I then posed the question: “Do you think Leo would be safer here with us, or out on the street?” The guests all agreed that Leo was far safer inside the shelter than on the street. One guest  added that because our staff were already very familiar with Leo, he would be better off staying with us than transferring to a new shelter. The other guests agreed.

“So, to summarize,” I said, “Leo’s behavior is very disruptive. No one feels unsafe with Leo, and we all agree that discharging him to the streets or another shelter would destabilize him and put him at risk of harm. So how can we work together to address his behavior here in the shelter so that each of you can get the sleep you need?”

During this process, the guests were able to reflect on the situation at hand through the lens of safety and harm reduction, instead of crime and punishment. As a result, it became apparent to many of the guests that that beneath their frustration, they felt genuine care and concern for Leo. They quickly brainstormed new tactics for minimizing his disruptions at night and shared best practices for how to speak with him in ways that calmed him down. Several guests volunteered to speak with Leo about whether he wanted to try attending support groups with them. Others who stayed up late at night offered to intervene when they saw him beginning to get disruptive.

By the end of the conversation, guests and staff had arrived at a resolution that minimized the harm experienced by all involved: Leo was able to be remain in the shelter, while the other guests were able to sleep with fewer disruptions. When those disruptions did occur, we had a clear method of responding to them based on care and concern, not animosity. As a result, what had originally been seen as a “problem” and a “rule violation” became an opportunity for community-building, deeper trust in one another, and democratic shelter management.

A harm reduction approach to shelter management doesn’t change the fact that community living, especially in emergency shelter, is a high velocity and complex experience. But the value of harm reduction is that it puts things in very simple terms: How can we respond to this situation without causing more harm?

It’s not always an easy question to answer, but it’s the right question to be asking.