Hello and welcome. I'm Shereen Khan, Vice President of Strategy and Operations at Thresholds, Illinois' oldest and largest provider of community mental health services. I also serve as social work consultant for SMI Advisor. I am pleased that you're joining us for today's SMI Advisor webinar, Mental Health and Harm Reduction, Meeting Your Clients Where They Are At. Next slide. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental health conditions. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Next slide. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one continuing education credit for psychologists, and one continuing education credit for social workers. Credit for participating in today's webinar will be available until May 15, 2024. Next slide. Slides are available from the presentation today, and you can download them in the webinar chat. Select the link to view. Next. Captioning is also available for today's webinar. You can click show captions at the bottom of your screen to enable. Click the arrow and select view full transcript to open captions in a side window. Next. We will reserve 10 to 15 minutes at the end of the presentation for Q&A, so please do submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. Next. Now, I'd like to introduce you to the faculty for today's webinar, Ms. Kim Davidson. Kim Davidson is a licensed clinical social worker and a BSW MSW social work instructor. Kim has been teaching social work for over 12 years, and she also provides therapy in a private practice setting and is a consultant for several local Chicagoland social work agencies. Kim has been practicing social work for 15 years and previously worked at Deborah's Place for 13 years as their clinical services director and a program administrator. Kim is passionate about exploring the intersections of gender, trauma, substance use, mental illness, and homelessness, and she works to incorporate this interest into her practice. As a personal note, Kim was my very first clinical social work supervisor when I was an intern at Deborah's Place, and she's the one who taught me all about harm reduction. So I hope you get as much out of today's webinar as I did out of my time with her as my supervisor. So, Kim, thank you for leading today's webinar, and I'll turn it over to you. Thank you, Shireen. Hello, everyone. Just to start my disclosures, I have no relationships or conflicts of interest related to this presentation, and here's what we're going to do today. I'm going to teach you about harm reduction. I'm going to teach you how to apply this in your work. We're going to start with what it is, then how you can do it, and I'm going to give you some ideas of things you can talk to people about as you're working with them around their mental health conditions as well as their substance use. So we'll talk about both of those. I'm going to also talk a little bit about change and sustain talk and help you be able to identify those when you're working with folks, and then my favorite thing in the world is to help people craft beautiful, open-ended questions that allow you to let your participants lead, and so we'll spend some time on how to do that. So why am I interested in harm reduction? This is something I'm super passionate about, and I'm going to try to cram it all into like 45 minutes. I started out in social work in an abstinence-only world where all of our programs required traditional mental health treatments or abstinence from substances, and my first internship when I was 20 years old was in Boston at a women's shelter, and I remember working with someone who had been on the streets for many years. She had many disabilities, and she was impacted by HIV, and she had finally stabilized in our housing program, and I saw her really start to thrive, and one night she came home intoxicated, and they met her at the door, and they said to her, if you don't do treatment, you're going to have to leave the program, and she left the program. I went back to school, and a few months later, I called the agency to just ask about people, and they told me that she had passed away in the alley behind the building of an overdose. I wish that this was the only story I knew that was like this, but this was the world that I started out doing this work in, and I spent so much time being like, I don't want to work in the mental health system. I don't want to work in this traditional world, but then I realized my problem wasn't mental health. It was the way we were approaching it with our folks. I ended up diving really into harm reduction from a mental health perspective, and I worked in a program that was HUD's Safe Haven model, which is designed for folks who have a chronic homelessness designation, been diagnosed with some form of severe mental illness, and who have not engaged in traditional mental health treatment, and the idea is to keep them out of institutions and house a highly vulnerable population that otherwise might be on the during this time is that if we take eviction and exits off the table, what that does is it forces us to have hard conversations, come up with creative solutions, and also think differently about success. Maybe our success can be that we keep someone housed and safe, and we help them live the best life they can with the tools that they have. I learned from them more than anything that we need to make shifts in our programs, and I'm going to share the tools that I learned with you today. I'm going to start with the textbook-y definitions of harm reduction, which include the things here. We have harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm reduction is also a movement for social justice built in a belief in a respect for and the rights of people who use drugs. Now this definition is about substances, but we can really apply this to any harmful behavior. We are really striving to reduce negative consequences. Also, harm reduction is an umbrella term for interventions aiming to reduce the problematic effects of behaviors. So we're really looking at the impact of the things that people are doing and trying to increase potential safety. Lastly, harm reduction is a reality-based approach that recognizes that drug use and other risky behaviors are a part of our everyday lives. Harm reductionists recognize that although abstinence may be a safe strategy, it is not feasible, appealing, or practical for all people in all situations. Recognizing that people are going to make the choices, they have a right to make the choices that they are going to make, and then we, in our role in their lives, is to be a guide to help them be able to reduce as many harms as possible. I'm going to share this beautiful quote from Gabor Maté, which is from the book In the Realm of Hungry Ghosts, which I highly recommend. He's a doctor that has a very harm reduction approach, and he says, if a cure is possible and probable without doing greater harm, then a cure is the objective. When it isn't, and in most chronic medical conditions, cure is not the expected outcome. The physician's role is to help the patient with the symptoms and reduce the harm done by the disease process. In rheumatoid arthritis, for example, one aims to prevent joint inflammation and bone destruction, and in all events, to reduce pain. In other words, harm reduction means making the lives of afflicted human beings more bearable and more worth living. The reality for a lot of the folks that you're working with who are navigating mental health conditions is that they will always have some form of symptom, and we are working to help them live the best lives they can, knowing that an ultimate cure is not possible and may not be the goal because they are who they are, and we want to help affirm that. So those are the textbook definitions, but let me give you my own definitions. We work with folks who have experienced immense harm trauma challenges, and we want to help them have the least amount of harms that they can in their lives. This also recognizes that sometimes the things that they're doing that make them feel better are their coping mechanisms, and if we get rid of those things, their life may not ultimately get better. So we have to meet them where they're at. We have to use empathy. We have to understand what's going on with them. This is not anything goes. Harm reduction is, in fact, the exact opposite. If we say to folks, you can get services here and be who you are, then they can tell us about the behaviors they're engaging in, and without withholding our services, we can have difficult conversations with folks because we all make bad choices. I do every day, and this approach has given me freedom in my work because when I started, I felt like I was responsible for the journeys of everyone I was working with, but all of a sudden, I started realizing that any movement towards safety is success, and then when you see it that way, you see success everywhere, and you learn to celebrate any positive change. Now, this is a wordy slide. I'm not going to dive into all of this, but these are the supporting principles of harm reduction from SAMHSA. I just want you to know that it is about autonomy, about support, about well-being, about relationships, about safety, and listening. These are important components to this approach, to an approach that allows people to really determine the direction of their lives. So I gave you a lot of big definitions, a lot of words. How does this relate to your work? We talk about harm reduction a lot just related to substance use, and we're going to recognize that a lot of times folks who are navigating mental health symptoms also are often using substances to cope, so there is a lot of overlap there, but even without that, the beliefs, principles, and basic strategies about reducing harm is really applied to any challenging behavior, and often when I was working with folks with pretty severe mental health diagnoses, their symptoms would place them in harm, and there were a lot of ways that we could reduce those harms that didn't involve medication or seeing a psychiatrist or going to a really structured program. We have to remember the goal, going back to that quote that we talked about before, is about reducing harm and not eliminating all harms, but what we see is once people start seeing that their lives can get better, I will tell you this, that often their challenging behaviors also get better, and they reduce those things because they start seeing themselves as worth taking care of. You want to start thinking about your work as helping people live the best lives possible, and we do that by helping them go in the direction of their goals, not ours. So why harm reduction? Well, if you don't believe me, we have a lot of research that says it works because it's effective because the themes speak to people universally. These themes of wellness and meeting people where they're at are really useful in having conversations with folks about wellness. It's really effective when we're working with folks with a lot of barriers and a lot of challenges going on because it allows us to prioritize and really look at where we can see a change, and it is an essential component of Housing First programs, programs where we're saying we're going to house you first because we recognize that housing is a right. In addition, it's important to remember that a lot of folks who've been diagnosed with a severe mental illness have parts of their brain where insight is living and happens that are impacted. So in the DSM-5 TR, we talk about this, and it is actually identified that not being aware of having an illness or symptoms is actually a symptom of schizophrenia, and that this symptom then impacts medication adherence and is connected to relapse, involuntary hospitalization, aggression, and more symptoms. So if you're working with someone and you're like, I don't know why they don't see what's going on, it may actually be a symptom of their mental health. And lastly, why use it? Because we want to challenge our own definition of success, and when I always try to ground myself in success, I go back to SAMHSA's working definition of recovery, which we're going to talk about a little bit more, which is about way more than just mental health specifically. It involves a whole plethora of the things that lead to wellness. So we talked about harm reduction and what it is. There's the definitions, and now we're going to talk about application of it, what we talk to people about, and how we have those conversations. So this is sort of the next section of this. Coming with us on our journey is a participant of mine from the past. I have her name changed here. I'm going to use the name Katie. Katie is someone I worked with for over 10 years. She had over 20 years of homelessness. I worked with her first as an intern at Deborah's Place when she was sleeping outside, and I worked with her in her drop-in program. Later, when I was working on my MSW, I worked in our interim housing program where she came through twice to move on to permanent housing and lost both of those housing opportunities. Then, years later, when I was working in our safe haven program, she came there. I remember a consulting psychiatrist at the time looked at me and said, this person, based on her history of housing, has a 100% chance of not keeping this housing. I'll never forget it because I said to her, I don't believe that's true for anyone. And it was not true for her. Her diagnosis was a bipolar disorder. She heard voices at times of extreme stress. She also had a pretty strong relationship with alcohol. In her times of being kicked in and out of housing programs, she was kicked out typically for violence, putting her hands on other participants or staff. Because of this, providers had struggled to have hope for her, and I consider her one of the biggest successes that I saw in my career. She's going to come with us on this journey. I want to start by talking about this idea that it's about more than symptoms. It's about more than substances. I want to talk about this famous study called Rat Park. Bruce Alexander did this study. He created two separate environments. There was Rat Park, which was a beautiful, big space for rats. Had lots of things for them to run around and do. They had lots of other rats that they could have intimate fun with and play with. And in this space, there was a dropper in the corner with some tasty liquid. It was sugary sweet and it had morphine in it. Even if the rats in Rat Park were already exposed to morphine prior to being in this cage, they hardly ever used it. That's one group. Second group, rats in tiny, confined cages with nothing to do but a morphine dropper. Those rats used it over and over again. They used 20 times more morphine than the rats in Rat Park. This study and other studies like it, there have been similar studies looking at folks who came back from Vietnam, highly addicted to substances, who came back to families and folks to show up to and no longer were using substances at the same level, have shown us that it is not just about the substance. That these other factors in our lives and relationships, housing, having things to show up for, a role in the world, these are the things that help people reduce harm. And so when we think about substances and symptoms, often the very first thing we want to think about is other stuff that we're going to talk to people about. Because if we want them to live the best lives possible, we also have to recognize that sometimes our programs look a lot like that second cage. And we need to adjust what we're doing to make space for a different way to see people. So whenever I think about what are these other things I talk about, I go to SAMHSA's four dimensions of recovery. So the first is health, but we're thinking of health holistically here. We're going to ask people about their physical and behavioral health from a very broad way. And recognizing that any positive change in any of these areas, even like preventative health care, is huge. Next is home. Access to permanent housing and also, I believe, beyond that, permanent housing that feels like home. A place that's yours. Next one, and I often felt that this was the most important, is helping people find that sense of purpose. Something to get out of bed for. This may be about employment or education or people to take care of. Like we would all engage people in activities within our community, within the outside community. And lastly, this idea of community. Social inclusion, acceptance, support. All of these things are what move us to make positive changes. And so when we're working with folks and trying to reduce harm, these are great things to talk about. So if we are taking a harm reduction perspective, what are other things we can talk about? We can talk about their symptoms. All of these questions, open-ended, non-judgmental, from a place of care and curiosity. We'll talk about that a little bit more later. What are their symptoms? When are they the worst? When are they the best? What have they tried in the past that makes them feel better? What helped? What didn't help? These are important questions to ask. Also, safety. This, to me, was the most useful thing I ever talked about with people. How can I help you feel safe? I don't know what it's like to navigate the world the way a lot of the clients that I've worked with did. But I knew that safety was a word they understood and wanted. And so that was often where we started. What will make you feel safer? What can I do to help? How can we change your apartment? How can we change your environments to make it feel safer? I would often say that in a traditional housing program, somebody would move in and we would say, here's the rules, fit into our program. And in our safe haven, we would say, welcome to our program. What do you need for this housing to work for you? And adapt accordingly. We also wanna recognize that sometimes these experiences create natural consequences. Going back to what I said before, harm reduction is not anything goes. We wanna talk about the natural consequences that they may have already experienced. Things like side effects of meds, hospitalizations, relationship ruptures, housing challenges, difficulties keeping housing or employment, and things that got in the way of their goals. And they may have experienced these or they might experience these in the future and it's often our responsibility to point those things out. Now, to have these conversations, you have to have first established a trusting relationship. So if you're not putting the time in on the front end, don't try to have these conversations first. I once worked with someone who, I love a metaphor by the way, who told me that a relationship is like a bank account. And when you're working with folks who have a high level of trauma, you start out with a negative balance. And so you kinda gotta make a lot of deposits before you start to take withdrawals. All of these questions are withdrawals. They require honesty and vulnerability. And so when we're first working with people, we need to invest, show up when we say we are going to do things, show them that we are a caring person, be empathic. Think of that relationship as the foundation of a house. If it's not sturdy, everything you build on top of it will not last. So that being said, we've got that strong foundation. When would we wanna have these conversations? A good time is after someone might have experienced a natural consequence. For example, if someone had to go to the hospital, or if someone lost an employment, or lost an important relationship to them, that might be a good time to have this conversation. Anytime someone says to you that they don't feel safe. I used to work with someone who would, and I will talk about her a little bit more as well, talk about being followed by a shadow person, and that made her feel very unsafe. And during those times we would say, okay, what can help? How can I make you feel safer? When someone is just starting to escalate or stray from their baseline, keep in mind that they are very escalated and screaming and yelling. They can't hear you. They're in their fight-flight-freeze brain, so don't have that conversation then. And then anytime we hear someone talk about change, which we're gonna talk about in a little bit, when we hear change talk, and then when something we're trying isn't working, like a creative solution. If behavior change isn't just about symptoms and treatments, it's important to recognize that we need to ask about these other factors, because we wanna understand where our clients are at, and evoking from them, not dumping in our advice is essential. So I have this little picture here because I have a friend who actually started at Thresholds, my social work mentor, who told me the story that she had been working with in outreach, working with a guy for a very long time who was housed, and they went to do his first home visit, and they were like, how's it going? And he was like, terrible, there's a monster in the backyard. I need you to move me. And so they spent all this time talking to him about this monster in the backyard and how there wasn't a monster. And he was like, sure, it's not true, he's safe. And then my friend was like, wait a minute, can you just show me this monster? And he was like, sure. And he takes her in the backyard, and there is a giant lizard in a cage in the backyard. And he's like, it's right there, and I'm terrified of it. And I always think about this, because we often think that we know what's going on, but we don't know. And the most important thing we can do is ask. So, the greatest skill I have ever used, I use it in my work life, I use it in supervision, on good days, I use it in my personal life, is motivational interviewing. And these core skills will help you have those conversations in a very, very thoughtful way. They keep us out of the picture, and if we're following these core skills, then we have to stay with the person we're working with. I think of motivational interviewing as pushing me to be mindful in my practice, because so often I can zone out. So, this combination of open-ended questions and reflections with some affirmations and summaries is a great way for me to be present. Because in motivational interviewing, for every one open-ended question we ask, this is super important, we have to reflect at least two to three times before we move on. Y'all, that is bananas compared to how we normally talk to people. We normally ask question after question after question. I always think of it as an open-ended question is like turning a page of a book, and then there's all the content there. And the reflections are how we read that content and make sure we really understand before we can ask another question and turn the page. So, even if you are just focusing on coming up with good open-ended questions and reflecting, you are really understanding where your folks are coming from. Affirmations are compliments, but they are specific and targeted to how the person is and how you see them. We use them sparingly. So, we do it too much, it's just too much. You know, sometimes compliments are like cringy and we're like, oh, I can't. And then lastly, summaries are how we kind of bring it all together. When we are coming up with questions, when we are trying to figure out what we reflect, we are listening for things like change talk. And this is any talk that favors movement towards a particular goal. So, I'm gonna go back to my example of Katie. She moved into our program and she could not sleep. She was up all night, constantly up, constantly agitated, constantly struggling. And then, because she was not sleeping, she was getting into conflicts with other people in the program. But we started realizing that she was also building in a relationship with the staff and with some of the residents and that this sense of community kept her wanting to stay. And we started hearing change talk. And I'll give you examples of each of these that we heard from her. Desire, I really want this housing to work. Ability, now that I'm finally in the same place, I might be able to take meds and see if they can make a difference. Reason, I don't want to fight with my neighbors anymore because I also really like them. Need, I can't be homeless, Anne. These are examples of the kinds of change talk that we are listening for. Even if someone is telling us all about how they want things to stay the way they are, if we hear these little nuggets of change, we reflect and we ask because that shows us that something has shifted. Then it moves towards mobilizing change talk. For Katie, she ended up deciding that she wanted to take Seroquel, a medication that she had taken before. She scheduled an appointment with her doctor, which was taking steps and a commitment. And then she started taking it regularly. It allowed her to sleep. And that was the first step in stabilizing her housing. So we're listening for change talk, but we're also listening for sustained talk, which is any sort of talk that favors keeping things the same. So desire, like I really don't want to take medication because when I do, well, I really don't want to take medication as desire. Reason would be when I take medication, I gain a lot of weight and it makes me uncomfortable, which was another one of Katie's concerns. If we don't honor that and have conversations about that, then we fail to see the full picture of what's going on with someone. All right, this was another thing that I learned early on in my career that was very helpful. So it's based on this book. It's from this book, I'm Not Sick, I Don't Need Help, which was designed to support family, friends, and providers in working with those who aren't interested in treatment. Now, this book is really designed to help them reconsider that, but I think the core tools are very in line with harm reduction and meeting people where they're at, because what the book is designed to do is help people reduce their defensiveness and their desire to tell people what's right, and instead to find ways to partner with them around their treatment goals. And it centers, going back to that foundation of the house, the relationship above anything else. The goal is to reduce any kind of resistance or discord and really help people feel seen and understand their experience. And I would often have people, because most of the folks that I worked with in my program heard voices, and I would talk to them about their day-to-day experience. Tell me about your work today. Tell me how you're feeling today. And sometimes my coworkers would be like, but aren't you just going down that rabbit hole with them? Say, no, not at all, because I'm gonna give you the example of the woman that I talked about who felt like she was followed by a shadow person all the time. Now, when she would tell me this, and sometimes I will tell you she would go in the shower in our program and just scream, like she had a very hard time with the things she was seeing and hearing, and she would tell me about it. Now, I wasn't like, oh my goodness, I'm gonna call the police right now and get them over here to arrest the shadow person. That would be going down this rabbit hole with her. Instead, I would say, it's so hard. How can I help you feel more safe? We all wanna feel seen. Her experiences were as real as this conversation is for all of you. And so how do we find those things that we can agree on? Wanting her to be safe, wanting Katie to be able to sleep, wanting folks to stay out of the hospital. And that's where we start. So what does this look like? What does LEAP stand for? The first is listen, deeply listen. And this is where those MI skills are so important because if we're listening and reflecting, then we're not telling anything. We are trying to understand what they think about medication, about their mental health, their hopes, their challenges. Not just, remember, we're thinking bigger than just the symptoms. Don't react, just reflect. Your family's really important to you. This has been a hard year for you. Really sitting with it. And then when we really sit with it, we empathize because we wanna truly understand and respond to their pain, their frustration, their fears, their goals, their hopes. That is essential. And then once we show that we understand, then we wanna show that we agree. We wanna normalize what they're going through. This is a common thing that people experience. And then we find areas of agreement and commonalities. Like, I know you hate going to the hospital and I hate having to be a part of you going to the hospital. We can agree on that. And then once we do, we find ways to partner. And maybe it's just, let's change your room around so it can feel a little safer. Maybe it's just, how do we help you at least sleep through the night? And maybe it's, how do we identify your trigger so you don't have to go to the hospital next time? I will tell you that I worked for many years in this program where most people didn't take medication, where most people walked around very symptomatic, living the lives that they wanted to live. And everyone felt seen and heard and a part of a community. And that is a powerful thing. And it really changed my understanding of what's possible when we think about wellness. So I'm gonna give an example of our friend Katie again. So our friend Katie, she got on the Seroquel. It helped with sleep. But her relationship with alcohol was pretty tight. And what she would do is a couple of times a week, she would go get a full fifth of vodka, drink the entire thing, and go from a very sweet and polite person to threatening to kill everyone in our program. And several times she nearly put her hands on people and we ended up hospitalizing her. And then pretty soon we realized that hospitalization, when she's like that, was like the only thing that we could do to keep her out of jail. And what we said was that every time she went to the hospital, when she came back, she had to come talk to me within the next 48 hours. And this is why those difficult conversations are an essential piece of harm reduction. I can't control her alcohol use, but I can point out to her the consequences of her actions. So she would come to meet with me and I would tell her, because she often was blacked out, what she missed. When she was having her time. And we would talk about her alcohol use. I would ask her questions like, tell me a little bit about your relationship with alcohol. And she would say, when I drink, I feel powerful and I need to feel that way because I felt powerless so many times in my life. I would listen to that because that told me way more about her drinking than anything else. And then empathize with her about what it feels like to feel so out of control in her life and how hard that was. And then we would partner on trying to just keep her out of the hospital in the future. And we try all different things. We would set little goals. One of her goals was to change the method in which she was using alcohol. So she would use wine instead of alcohol. She would use wine instead, which worked for a while. One of the most powerful things we came up with was her getting a hotel room and staying in the hotel room a couple of days a month where she could just drink as much as she wanted. And then in that hotel room, she could feel powerful and strong. And then she could come back to the program and maintain her housing. This ended up being a really powerful tool for her to maintain her housing. So we're gonna explore other things when we're working with folks, right? Because we're not just gonna talk about a diagnosis. And outside of the LEAP skills, the motivational interviewing skills, which really make a huge difference, we can also talk about their lived experiences and their symptoms. I can tell you, I've worked with a lot of folks diagnosed with schizophrenia, and every one of them navigated the world completely different, had a different experience with what they were seeing or hearing, and needed different things to feel safe. And so a one-size-approach for everybody would not have worked to keep people housed. And so it was really important for me to understand, were the things that people were seeing and hearing positive and supportive for them? And a lot of times they were. Or were they tormenting them? And when that happened, what did that look like? We would actually talk about the content of their voices if they had that level of awareness. If they didn't, we would talk about what they were experiencing and the stress related to that. And I would also talk to people about the real impact of trauma. So I worked with folks who had experienced very lengthy periods of homelessness, usually over 10 years. And navigating that environment where you are always on edge and always kind of vulnerable, especially I worked with women navigating homelessness, there's very high levels of trauma and the mental health impact just of that is real. And so having conversations just about the impact of trauma sometimes took the stigma out of conversations about mental health and reminding people that you had something happen to you that was painful and hard, and you didn't have a choice in that. And so what you're feeling right now is normal, and how do we make you feel a little bit better? One of the most useful things that I did often was in this next category, which is creative solutions. I love a creative solution because it was really that idea of what do we need to make this program work for you? Very early on in the program, when I became the administrator of the Safe Haven, I remember we had a participant who believed she worked for Homeland Security, and she didn't have any income, and she would sit in our back room and take notes all day for the government. And we had a rule that people couldn't watch TV between the hours of nine and five, which was the idea was that then they would be out in the community attending groups and all of these things. So when I started in the program, I went back and I was like, excuse me, and she was like, well, if you're watching TV, she would sneak the TV, right? And it was like 10 a.m., and I was like, you can't watch TV. And she was like, well, I'm a grown woman. I was like, well, you can't watch TV between nine and five. And then she was like, but I wanna watch TV. And I unplugged it. And she was like, I have to watch TV for my job. And we got in this huge fight. I was like, well, and I was like, you just can't watch TV. And then I walked away and I thought about it, and I was like, why can't she watch TV again? She doesn't have an income, and everybody else with an income is in this space all the time. And I realized that the way that we were trying to control the folks in our program was not working and helping them live their lives. So I actually started my time in the program by going on a year-long journey, which I thought would take one staff meeting, to work on our program rules and completely rewrite them. I thought it would be one meeting. Someone very wise told me that a rule is all about safety, and all of your rules need to be about safety. So someone says, why is this a rule you say to keep you safe? And if you can't answer with that, then it's probably a guideline and not a deal breaker. And so we adjusted our requirements in the program to make it much more flexible for the needs of the folks that we worked with. We also help people with things that would make them feel safe. Like sometimes in our apartments, people wanted to put like a little alarm on their door so they would know if it opened, and that made them feel safer, especially after years of homelessness. We would help with lighting. We would help people keep their doors open if that was something that made them feel safer. And a big thing was like helping them adjust to noise. Headphones for people that heard things would often be helpful, or having just ongoing noise. Noise machines, sometimes that like noise was helpful. And sometimes if people lived next door to someone who was like yelling or screaming, we would get them a noise machine. Grounding techniques. All of these things that are therapeutic that are not therapy, but like helping people with deep breathing, helping people come back in their body, super important. Helping people get an income. Exploring social security and SSDI. And recognizing that to do that, sometimes they might have to talk about their mental health and get treatment and helping them weigh the pros and cons of that. Sometimes was in line with that agree and partner. We could agree that they wanted a stable income to eventually be able to see their life looking differently. And then we would partner to reach that goal. And sometimes a different living environments. I learned that for some people, having an apartment with a key and a door that closes can be really scary. And so in our safe haven program, folks slept in bed spaces next to each other and they were 24 hour staff. And that was the most useful thing for them. And we actually had two people that started in our apartment building, which I also was an administrator of. And they moved voluntarily to the safe haven so that they could have a little bit more community. And lastly, different ways to access peer support. So all of these websites here that are linked are organizations that are participant driven and that focus on alternative ways of looking at mental health. In particular, the Hearing Voices Network is all about bringing people that hear voices together and also having a different approach to seeing and understanding voices. And living room models are alternatives to hospital emergency rooms, where folks can go and be evaluated if they're in mental health crisis, and then also meet with a peer support specialist that will just help them and talk to them. So these are ideas of other things you can explore when you are working with your folks. So I wanna end with Katie, my participant that has walked with us on this journey. She taught me a lot, probably more than I have taught my students over the years. She taught me the importance of hard conversations. Sometimes she would go to the hospital and we would just be so tired. I remember staff meetings where my staff were like, how are we gonna keep doing this? This is just not good for us and not good for the program. But just being able to say, we are just going to be consistent with her. Even sometimes when I was so tired from having to come in and navigate a crisis that she had instigated, I still had those conversations every time because what I saw is that progress did happen. I also saw the importance of creative solutions. So other things that we noticed as we got to know her is she had a lot of anxiety in a day-to-day basis. And actually she would stray from her baseline the entire week before her social security check arrived because she knew that when it came, something bad might happen. She might use the money on something that might get her in trouble or help her lose her housing. So we did a lot to keep her busy. We found a board game that she loved. And my poor interns, and I actually wonder if Shireen was one of them, used to end up playing board games with her for hours at a time just to keep her busy. She also would wash all the dishes in the program. She loved it. She said that it gave her a sense of giving back. And I remember one time she went to bed and one of my staff members went in the kitchen, took all the dishes that she had washed and rewashed them. And I was like, what are you doing? And she was like, she doesn't do it the way that we need to for food sanitation, but we let her do it because it just means so much to her. So recognizing the ways that people can give back. Flexibility, being willing to change your roles, being willing to acknowledge that you might not know. There's a video I really like with William Miller talking about motivational interviewing. And he says, you want to be willing to recognize that there's an expert sitting across from you. So being able to use those open-ended questions to let them share their expertise about their lives. And lastly, the importance of LEAP, listening, empathizing, agreeing, and partnering. I really did see some powerful changes with that. That is what I have for you today. I do see some Q&A and I know we wanted to leave about 15 minutes for that. So let's do it. What questions do you have for me? I know that was fast. I'm usually like way more interactive, but here's a lot of y'all. So I didn't know how to do that. So here we are. There are a lot of questions. Just before we get into that though, you can, I just want to let people know that you can access SMI Advisor from your mobile device. And so you use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating skills, and even submit questions directly to our team of SMI experts. So you can download the app at smiadvisor.org slash app. So yes, there's a lot of comments. I've been keeping track of them and I've kind of tried to like maybe consolidate some that are similar. So we'll go ahead into that. And I will, there's a slide on this after, but I just want to let everybody know if we don't get to your question, or I did see like a specific case example, you can submit a consult on SMI Advisor and either me or if we need, we can actually route it to Kim to help us answer that. So just so you know, if we don't get to you today, we do have a consultation option. So I'm going to start with a first, like an internal question focusing on you as the clinician. So how can we manage our own implicit bias or prejudices when it comes to harm reduction? Yeah, my goodness. I remember really early on my first harm reduction job, one of my coworkers came in and he was like a harm reduction mentor for me. And he was like crying and he like threw everything off of his desk and he had just found one of his clients who had overdosed. And since then, I have also lost a few of the folks that I work with from substance use or from some challenging behaviors, right? And it is hard. And I just want to start out by acknowledging that it is hard. What I believe is that doing it any other way and like not working with those folks is even harder. And so over the years, I recognized the work and I think this question speaks to that is mine to do. There's a metaphor that I really like. I love metaphors, y'all. It's two mountains. I was in a training once and they shared this. So it's like you imagine, it's like the therapeutic relationship, right? So there's one mountain and another mountain. We're all on a mountain in this world. The only difference between us and our clients is that we have distance and vision. If we stay on our mountain, then we can see them from a distance and we can say, well, it looks like it's getting hard up ahead. This might be challenging. But we also recognize that we all go on our mountains differently, right? So like for me, I don't exercise. So if I have to climb a mountain, I'm gonna get really out of breath and I might fall over and Shereen, you might run right past me. And so the only way we know is to ask. And so sometimes when we are really caught up in our clients' lives, we're on their mountains. We're like, get on my back. I know how to do this. And so I always tell folks to just kind of go back to that metaphor and say, how do I stay on my mountain? How do I keep that distance and vision? How do I know that this is their journey and that the best way I can support them is with that distance? That's the best way for me to partner and guide. I don't know if that's helpful, but that has been helpful to ground me through the years because our ultimate goal is to keep people in care. And we know that that is what works. Telling people what to do, unfortunately just doesn't work. It doesn't work for me. I hate it. If you told me how to handle this Q&A right now, Shereen, I would be pissed. I would be like, no. Yeah, I think that is helpful. And I think the person even asking the question shows that they're on the right path for that. So now let's talk about other people and then we'll talk about client-specific questions. So there were several throughout. A lot of people say, kind of how do you navigate using harm reduction techniques when either it's kind of like a three-parter, your colleagues don't agree, or your organization isn't supportive, or even like societal structures aren't necessarily like set up to support this model. So however, if you want to break it down, start colleagues and organizations and systems or however you want to try to approach that. But there was a lot around, they believe it, but what do you do when the system structure doesn't support it? I think there is something to just like recognizing that within that, there's only so much you can do. And it really is about like, what does your agency consider its deal breakers? I do a lot of consulting with organizations to help them figure out how to be more harm reduction. Because what I see is agencies being like, well, we just ask people, like, do you use substances? Do you have mental health? And if they say yes, then we don't accept them. And I'm like, well, those are the people that are at least on a journey of their like, and so then they end up with folks in their program and they're like, wait, how did this happen? Now what do we do? And so recognizing that this is everyone that you work with, right? This is everybody. So just continuing to bring that to your colleagues. And I think helping people see the other successes. For me, the biggest one was maintaining housing. Our numbers were like 99% for that. That's huge. And so I would talk, I would look with my coworkers around other outcomes and see how to focus and just consistently, I mean, there's no, I mean, honestly, like sometimes it is also figuring out if that's the right agency culture for you. But also moving into leadership for me allowed me to help operationalize harm reduction into our policies a little bit more. We did things like incorporate eviction prevention programming. And so really trying to help people who are in danger of losing their housing. So there's different ways to like incorporate it into your policies. And I think, hold onto your hope. Remember it works. There will always be those colleagues. They exist everywhere. I've had so many people in my life be like, you are just too positive and hopeful. But I can be serious when I need to. I also had really amazing relationships with the folks that I work with and I could hold them accountable as well. And so staying true to your values as a professional, I think is really important. Right, thank you. Okay, so now there's some specific questions to like using the harm reduction techniques with different types or groups of people. So one is, do you have any recommendations or tips around how to use harm reduction with the chronically unhoused population? So people that might even be like resistance to housing, right, things like that. So anything specific to that population? Oh gosh, yeah. I, this is my, these are my folks. This is what I love to do. I think it's however you can small, small changes. When I would work in outreach, the most important thing I did was give socks and underwear to people. Because when it's cold out, they need socks and underwear. And sometimes I would let them just sit. Like if we have people who wanted to stay in the safe haven, they were unsure, we would do tours and we would let them just come and sit and have a meal in the program and get comfortable and have conversations there. I think it's any way, and I always go back to safety. Like what can we do to help people feel their safest? If we had someone who slept in our laundry room for the first three weeks, she was housed because her apartment scared her so much. And actually she slept in our laundry room after she never slept in the building and we called the shelter she was at and they were like, what do you mean she's housed? She's been coming back here every night. And so I think it's really just patience and also recognizing that change is so hard. There's a quote I really like that like, therapists know more than any other folks that like with every change, even positive comes loss. And when someone is leaving homelessness, they often lose a huge community. They lose the people that they know and connect with. And if you can't help that bridge, like people get scared in apartments by themselves. It's quiet. Like so often I hear clients say like, the quiet is terrifying to me. And so really just trying to understand their experience. That's what I recommend. There's an assessment tool that I really like. I recommend the website org code, O-R-G-C-O-D-E. They're a consulting group and they have like just a few handy documents. One is, and Shereen, I can give you this, that you can email folks, but they have like a real life budgeting thing, but they have a quality of life tool. So you give it to someone like a week or two after they move into housing and you ask them like, is your sleep better or worse? Is your mental health better or worse? And give them the opportunity to say, yeah, it's worse. So having those conversations with folks and then they also have like a week of meaningful activities schedule. So you can help people schedule their days because a lot of times in a shelter, there was something to do. You know what time you eat breakfast, you know what time you eat lunch, you know what you're gonna eat. And so helping people like kind of build out that structure. So people were asking for some of the things that you, some of the references. So I just put orgcode.com into the chat. I don't know if there's any, if there's other, some of the other books that you referenced, right? Maybe if you could list a few suggestions. So honestly, the motivational interviewing book is just so good. Anything motivational interviewing is gonna like, you can use those tools for harm reduction. It is so powerful, I think. Because to me, harm reduction is so personal to the harms that the person you're working with is facing. So that to me has always been the most useful. A lot of books are gonna be about like the theories of it or the approach, but like also any workbooks that you find, like I have a couple, I recommend like I look up harm reduction workbook, motivational interviewing workbooks, but really just any motivational interviewing handouts. Like there's so much online that you can find that's like free and good. Any like videos from William Miller, so good. There's an amazing YouTube video of him doing MI with a resistant person that's mandated. It's called The Silent Man. You just look up William Miller, The Silent Man. It's hard to find because it keeps getting taken down. But it is amazing to watch like a really brilliant like reflection. Because you start to see that you can reflect what someone says, but you can also reflect their body language. You can reflect so many other things. I think people are throughout the chat feeling very much like your compassionate empathic view. And so I think they are, so people have also asked, how do you take care of yourself? So as a clinician who's dealing with kind of a population that really that other people don't wanna deal with, how do you make sure that you still kind of maintain your own sense of wellbeing? So any tips around that, around how to manage burnout or yeah, just take care of yourself. It has been a journey for me, y'all. I would say boundaries. It's probably the thing I talk about the most and really the boundaries. I wanna go back to that first question that someone asked about boundaries. It was really boundaries question. Like how do I stop myself when I am feeling caught up in someone's journey? Those are the boundaries that for me have been the most important to protect, knowing where I end and where the client starts, doing daily practices and things that just like fill me up, not overly identifying with my work. And if I'm honest, I don't have the same job that I had when I first started. I couldn't. I feel like I had to also come to terms with the fact that like some of my work had an expiration date that I started. I remember one time when I was working in the safe haven and I was sitting at a table and one of our residents sat with me, because I spent a lot of my life there, if I'm honest, and she sat down and she said, you're gonna leave us soon. It's just not the same for you anymore. And I was not aware of that. And I realized that like my ability to be present for the folks that I, the clients wasn't the same, but that I can make a bigger change with what I learned from them, which is actually how I walked into this webinar today, because this isn't most people I've ever trained in my life, but I do mostly training now. And I do that because somebody once said to me, you wanna make change in social work, train social workers. And so I think about my teaching like that. And so I think for me, it's always like, where can I do the most good with what I know and the ability to feel useful in my job gives me a feeling of empowerment. And I think that that translates into the folks that I work with. Well, thank you again. This was very powerful and remind me of why, yeah, how much you've impacted my journey too. If you can, can you pull the slides back up? We just have a few wrap up slides just so people can share. Starting with the consult slide. I'll start talking while you try to pull them up. Okay, perfect. I think should put it in the next one. Yeah. Okay, cool. Let's see. Maybe one more. And then one more. Is there more? Okay, great. So I already did the slides to the next one. So if, oh, next one. If there are any topics, as I mentioned, that weren't covered in the webinar that you would like to discuss with colleagues or that were covered in the webinar that you wanna discuss with colleagues in the mental health field, you can post a question or comment on SMI advisors discussion board. So that's an easy way to network and share ideas with other clinicians who participated in this webinar. And if you do have any questions about this webinar or any other topics related to evidence-based care for people living with serious mental health conditions, you can submit a consult and get an answer within one business day from one of our SMI advisor national experts. And this service is available to all mental health clinicians, peer support specialists, administrators and anyone else in the mental health field who works with people who have SMI and it's completely free and confidential. So next slide. SMI advisor offers more evidence-based guidance on harm reduction, such as skill building interventions for individuals with SMI and co-occurring substance use disorders. This implementation guide is designed to provide helpful tips for service providers working in mental health settings, serving people with serious mental illness who may also have co-occurring substance use challenges. And you can access that by clicking the link in the chat or by downloading the slides from there. Next slide. To claim credit for participating in today's webinar, you need to meet the requisite attendance threshold for your profession. After the webinar ends, please continue to complete the program evaluation. The system then verifies your attendance to claim credit. And this can take up to one hour and can vary based on where you're located and the usage of the Zoom platform. And then our last slide, please join us next week on March 21st as Jose Viruet, LCPC presents strategies to increase staff morale retention and decrease burnout in the mental health workforce. Again, a free webinar on March 21st from 3 to 4 p.m. Eastern. Thank you so much for joining us and for your time. Thank you again to Kim and until next time, take care.

SMI Advisor webinar

Kim Davidson

harm reduction techniques

motivational interviewing

mental health support

trauma recognition

safety measures

community building

professional boundaries

staff morale