Services for the UnderServed (S:US) is one the largest community-based health and human services organizations in New York State that works intentionally daily to right societal imbalances by providing comprehensive and culturally responsive services.
The pandemic has deepened many of the wounds already affecting the world. It is known that the pandemic hit those hardest who were most likely to experience barriers to medical care, housing, employment (especially the ability to work safely during the beginning of the pandemic), and other protective factors against problematic drug use.1 Due to the fact that over 90% of the people served and employed by S:US identify as Black, Indigenous, and People of Color (BIPOC), it is essential to highlight the drastic increase in racial and ethnic disparities during this period. One of the areas of concern for S:US, like the rest of the state, is that the overdose crisis has worsened in the past three years in New York City yet challenges to accessing care remain. A commonly discussed barrier to accessing care is stigma. While much of the literature around stigma and access to care focuses on perceptions of those served, stigma held by those in the system of care can have a deadly impact on those we serve.2
In this context, we understand stigma as “an attribute that links a person to an undesirable stereotype leading individuals to reduce the bearer from a whole and usual person to a tainted discounted one.”3 Aside from dealing with the stigma of race, poverty, and mental illness, people struggling with substance misuse are also highly stigmatized as untrustworthy, blameworthy, and dangerous,4,5 hindering their help-seeking behaviors.6,7 Another barrier to accessing behavioral health care for underserved communities is the perception (often accurate) that the medical field has a long history of racist and disparate practices based on socioeconomic status. This phenomenon plays out in providers who are less likely to offer medication for addiction to people of color and women, and counselors whose experience pre-dates harm reduction are more likely to promote abstinence-only models, despite the evidence demonstrating these punitive methods of care to be less effective.8 In the field of substance use care, stigma can have deadly effects. This outcome is evident in the escalation in overdose fatalities, overcoming practitioner stigma through a culture shift in training, supervision, and approach that has never been more critical. For a service provider in New York City, the intersection between diversity, equity, inclusion (DEI), anti-stigma, and harm reduction means saving lives. S:US has intentionally adopted interventions that honor the full agency of persons served.
In the past five years, S:US has embarked on an agency-wide effort to shift toward harm reduction and holistic care. We believe that harm reduction interventions foster the idea of complete acceptance of persons served and their journey. The basic tenet of harm reduction at S:US reminds all staff that even when people use substances that can cause harm to them, their lives are just as important as any other lives and that we must demonstrate our belief via our care and services. Staff are trained during new hire orientation to administer Narcan, which is medication to treat any known or suspected opioid overdose. Kits are readily accessible in all of our locations. Our outreach teams provide harm reduction services such as fentanyl strip testing, Narcan training, access to shelters, and support services on many other social determinants of health to New Yorkers experiencing street homelessness. Clinicians at our two clinics and satellite are trained in harm reduction, anti-stigma psychoeducation, and overcoming their own internal biases regarding medication, acceptance of relapse in persons served, and other challenges to positive countertransference. S:US is launching a Public Health Vending Machine later this year, in partnership with the local health department. The machine will provide free harm reduction products for safe use, sexual health, as well as feminine care supplies, along with information on services available.
But effective harm reduction is more than handing out Narcan kits and training clinicians.9 Harm reduction is about ameliorating conditions that make it challenging for the person served to meet their overall life goals and recognizing that social identity reconstruction is critical for recovery10,11,12 of people served. Effective support means demonstrating harm reduction practices daily, providing anti-racist care, and undoing systemic harm by the entire agency embodying the mission, from the front door to the services provided.13
Here is an illustration of how we operationalize S:US’ core values to eradicate stigma using a harm reduction framework that honors the full agency of persons served:
Respect for all: The staff see persons served as whole human beings whose lives matter and then in partnership with persons served, identify stages of change the persons served are in and offer interventions to meet them where they are.
Integrity in all actions: Staff is aware of their institutional power and shares that by following the lead of persons served and reminding them of their role as the subject in charge of their recovery.
Maximizing individual potential: Staff offers persons served all available resources to maximize safety in all their choices so they can live another day and achieve their goals.
Continuous quality improvement: Staff uses strength-based approaches to remind persons served of their past successes, resilience, willpower, and commitment to recovery and motivate them to reach for far more and better.
Supportive culture: The staff provides strong representation and the ability to connect through shared culture, experience, and understanding. It also means the staff has experienced the same systemic barriers and injustices as persons serve.
Commitment to creating opportunities for all: Persons served are encouraged and offered the right tools to meet their life goals of acquiring jobs, becoming parents, graduating college, moving into an apartment/home, getting married, and volunteering just like people in their communities who are not living with a substance use and or mental health diagnosis.
S:US creates an environment of collective healing and empowerment by celebrating and supporting persons served and staff accomplishments, including healing care for people with mental illness, persons with substance use, those experiencing housing instability, etc. Through the complete acceptance of a person served’ s full humanity, S:US creates the space where stigma is eradicated, and care is empathetic and person-centered.
Nadjete Natchaba, EdD, LCSW, MPA, is Acting Chief Operating Officer, and Rebecca Linn-Walton, PhD, LCSW, is Chief Clinical Officer, at Services for the UnderServed.
Park, J. (2021). Who is hardest hit by a pandemic? Racial disparities in COVID-19 hardship in the US. International Journal of Urban Sciences, 25(2), 149-177.
Bagley, S. M., Schoenberger, S. F., Lunze, K., Barron, K., Hadland, S. E., & Park, T. W. (2023). Ambivalence and Stigma Beliefs About Medication Treatment Among Young Adults with Opioid Use Disorder: A Qualitative Exploration of Young Adults’ Perspectives. Journal of Adolescent Health, 72(1), 105-110.
Goffman E (1963) Stigma: Notes on the Management of Spoiled Identity. New York, NY: Simon and Shuster
Livingston JD, Milne T, Fang ML, et al. (2012) The effectiveness of interventions for reducing stigma related to substance use disorders: A systematic review. Addiction 107(1): 39–50.
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Fitzgerald T, Purington T, Davis K, et al. (2004) Utilization of needle exchange programs and substance abuse treatment services by injection drug users: Social work practice implications of a harm reduction model. In: Mancoske R, James S and Shelby D (eds) Practice Issues in HIV/AIDS Services: Empowerment-Based Models and Program Applications. NY: Routledge, pp.107–125
Hartwell S (2004) Triple stigma: Persons with mental illness and substance abuse in the criminal justice system. Criminal Justice Policy Review 15: 84–99.
Michaud, L., van der Meulen, E., & Guta, A. (2023). Between care and control: Examining surveillance practices in harm reduction. Contemporary Drug Problems, 50(1), 3-24.
Murray, B. J., Copeland, V., & Dettlaff, A. J. (2023). Reflections on the Ethical Possibilities and Limitations of Abolitionist Praxis in Social Work. Affilia, 08861099221146151.
Hughes K (2007) Migrating identities: The relational constitution of drug use and addiction. Sociology of Health & Illness 29(5): 673–691.
Koski-Jannes A (2002) Social and personal identity projects in the recovery from addictive behaviors. Addiction Research and Theory 10: 183–202.
McIntosh J and McKeganey N (2000) Addicts’ narratives of recovery from drug use: Constructing a non-addict identity. Social Science & Medicine 50(10): 1501–1510.
Tóth, M. D., Ihionvien, S., Leduc, C., Aust, B., Amann, B. L., Cresswell-Smith, J., … & Purebl, G. (2023). Evidence for the effectiveness of interventions to reduce mental health related stigma in the workplace: a systematic review. BMJ open, 13(2), e067126.
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