Harm Reduction and Tensions in Trust and Distrust in a Mental Health Service: A Qualitative Approach

Abstract

BackgroundPeople seeking care for substance use (PSCSU) experience deep social and health inequities. Harm reduction can be a moral imperative to approach these persons. The purpose of this study was to explore relationships among users, health care providers, relatives, and society regarding harm reduction in mental health care, using a trust approach rooted in feminist ethics.MethodsA qualitative study was conducted in a mental health service for PSCSU, and included fifteen participants who were health care providers, users, and their relatives. Individual in-depth and group interviews, participant observation, and a review of patients’ records and service reports were conducted.ResultsThree nested levels of (dis)trust were identified: (dis)trust in the treatment, (dis)trust in the user, and self-(dis)trust of the user, revealing the interconnections among different layers of trust. (Dis)trust at each level can amplify or decrease the potential for a positive therapeutic response in users, their relatives’ support, and how professionals act and build innovations in care. Distrust was more abundant than trust in participants’ reports, revealing the fragility of trust and the focus on abstinence within this setting.ConclusionThe mismatch between wants and needs of users and the expectations and requirements of a society and mental health care system based on a logic of “fixing” has contributed to distrust and stigma. Therefore, we recommend policies that increase the investment in harm reduction education and practice that target service providers, PSCSU, and society to change the context of distrust identified.

Exclusão social vivenciada por pessoas dependentes de drogas e seus familiares: revisão integrativa da literature

“…Destaca-se a importância de valorizar os grupos de apoio/suporte, pois configuram-se como estratégias que auxiliam as famílias a se fortalecerem e a lutarem pelo bem-estar do grupo, por meio de troca de experiências, escuta qualificada, abordagens terapêuticas mais humanizadas, condutas que respeitem a cultura, a história, as crenças e as decisões das pessoas. Desta maneira, os grupos são eficazes para auxiliar os sujeitos a se empoderarem, a desenvolver estratégias de autocuidado e estimular ações de protagonismo dos usuários de drogas, para que possam lutar a favor do seu direito à saúde (6,13,(24)(25) .…”

Guidelines to destigmatize harm reduction: How stigma and misperceptions impede benefits of evidence-based drug policy

“…4 This ideology can be at odds with the complex needs of people who use drugs, and it can create tension, distrust and stigma in health care settings . 17 Patients report feeling like health professionals give up on them when their addiction, mental health and social needs are too complex to be efficiently met. 4 Health professionals report feeling like they've failed people when their services cannot resolve the social and health needs of clients with substance use problems.…”

“…• Practicing with a harm reduction mandate may increase trust, improve relationships and enhance job satisfaction. 17 • See the table on page 14 for an overview of "Harm Reduction Principles for Healthcare Settings" as presented in the research of Hawk et al 2017. 6 Harm Reduction Principles for Healthcare Settings Hawk et al 2017 6 Principle Definition Approaches…”

“…Additional benefits for people who use harm reduction programs include increased opportunities for social connection and support, feelings of belonging, and improved attitudes toward their addiction, all of which contribute to better treatment outcomes and overall quality of life. 17,18,43 Note: It is important to note that some harm reduction programs include drop-in centers, access to counselling and social services, and hot meals. These additional services resolve some basic needs of people with substance use disorders and likely contribute to the positive outcomes outlined above such as reductions in drug use and drug-related crime.…”

“…• Their resilience in surviving and overcoming horrific circumstances, such as societal marginalization, family dysfunction, abuse, neglect, traumatic injury and loss, is a testament to the human spirit . 13,14,15,16,17 Case examples: ý Kate has been on pain medication for 14 years for injuries from a car accident. When she was trying to get into an opioid replacement program that required drug screen testing, her pain medication prescription was cancelled because other illicit drugs were found in her system.…”