Provider views of harm reduction versus abstinence policies within homeless services for dually-diagnosed adults

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 supportive housing 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 distinctly different approaches to homeless services: the traditional or ‘treatment first’ (TF) approach that requires abstinence and the more recent Housing First (HF) 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 a harm reduction versus abstinence approach. Themes included: (a) harm reduction as a welcomed alternative; (b) working with ambiguity; and (c) accommodating abstinence. Drawing on recovery principles, we consider the broader implications of the findings for behavioral health care with this population.Peer reviewe