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Learn More About Harm Reduction

BY JUDITH TACKETT

Lately I have been working with a couple of organizations and talking about onboarding new team members and implementing ongoing staff training. As part of the training curriculum, we discussed the importance for staff to learn about harm reduction.

Harm reduction, I found, is one of those terms where everyone thinks they have a good understanding, but then, when it comes to implementation, it becomes clear that many of us still have a lot to learn.

Furthermore, I have experienced situations where a few well-intentioned advocates and volunteers equated harm reduction as a “no-rules” approach. Let me be clear. Harm reduction does not negate program rules. Let me talk about a specific example I observed a few years ago during a winter shelter program run by Metro. The overnight cold weather shelter included a rule that people can go outside to a designated smoking area throughout the night, but they could not go outside to drink. The shelter was open for people who came in intoxicated. However, they were not allowed to drink on the premises. The reason was that when you have dozens of people come into a large room, you need to create a safe space for them to sleep out of the cold. Therefore, it was necessary to ensure that people were not actively drinking or taking drugs throughout the night. Some advocates blamed Metro for creating a high-barrier shelter that violated harm reduction principles.

Not so, I say.

Low-barrier access and harm reduction do not mean people don’t have to follow rules. We all have to follow some rules in society and communities to live together peacefully. So, let’s talk about harm reduction.

Harm reduction has been mostly associated with an approach or strategy to reduce the risks and harmful effects of drug use. The federal Substance Abuse and Mental Health Services Association (SAMHSA) defines harm reduction as, “an approach that emphasizes engaging directly with people who use drugs to prevent overdose and infectious disease transmission, improve the physical, mental and social wellbeing of those served, and offer low-threshold options for accessing substance use disorder treatment and other health care services.”

When working with homelessness, however, a lot of us expand the meaning slightly to focus on a person-centered approach including substance use and mental illness. In his book called Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction, Dr. Sam Tsemberis, who introduced the Housing First concept to us, defined harm reduction as, “a practical, client-directed approach that uses multiple strategies, including abstinence, to help clients manage their addictions and psychiatric symptoms. Harm reduction focuses on reducing the negative consequences of harmful behaviors related to drug and alcohol abuse or untreated psychiatric symptoms. With harm reduction, staff ‘meet clients where they are’ and start the treatment process from there, helping them gradually gain control over their harmful behaviors.”

I would like to point out that Tsemberis specifically includes abstinence as an option. However, it is not a requirement. The goal is to minimize risky behaviors and do so with an individualized approach.

One of the key aspects to me is to look at the options we provide people with substance use and/or mental illness in our community. If we have programs that offer abstinence, that’s one option. If we have programs that allow people with active addictions, we have another option. The point is to focus on solutions for each person and celebrate progress, whatever that progress or positive change looks like. To do so, we need to offer a diversity of programs within our community.

Generally, I believe it is hard for us to accept that the most effective interventions are client-driven. If we are being honest, pretty much all of us start with a perspective where we feel we have enough experience to know what’s healthy for another person, and in our eagerness to help, we are inclined to impose our solutions on that person. And when that doesn’t work, we are disappointed and try to find fault with ourselves or the other person who would not do as we told them. It usually doesn’t occur to us that maybe we did not listen to each other, we did not take the time to build a trusting relationship, and we actually disempowered the person we claimed we wanted to help.

Let’s be honest. Is taking a person’s choices away truly helping them? And that’s where harm reduction’s focus is to meet people where they are and help them think through all the options they have. Then let them make their own decision and support them. And remember, that does not mean there are no rules to follow within a program.

When I speak about options and choices, I don’t necessarily say they have to be within one program. On the contrary. Take abstinence for example. People who want to be in an environment where sobriety is provided should have that option. But those programs then cannot also host people who choose to reduce their substance use but do so gradually. Therefore, we need different program options at the community level.

One definition I found was from the Canadian Homeless Hub. It states that, “harm reduction is an approach or strategy aimed at reducing the risks of harmful effects associated with substance use and addictive [behaviors] for the individual, the community and society as a whole.”

By the way, our city’s current encampment closure protocol (as implemented right now) is not focused on harm reduction. For one, it’s location-centered rather than person-centered. Secondly, officials distort evidence-based approaches such as the importance to build relationships with each person and have them be a driver in their own solutions by offering different choices (two options of temporary housing locations are not really a choice). When have we ever built meaningful relationships in our own lives on a timeline of three to four weeks? Hardly ever. So why do we think that by giving people in a specific encampment a notice of three to four weeks and an assessment will help create meaningful relationships with government officials? And finally, if the entire group is offered to move into a temporary location together, are we really taking an individualized approach or are we just moving an encampment indoors?

I feel strongly that a better solution would be to implement a person-centered approach where we focus on the path to housing for each person. This community often forgets that prior to the Jefferson Street and Brookmeade encampment closures, our community providers housed more people and reduced the overall number of people in those encampments steadily without the added stress of rushing the process. Taking an individualized approach was more focused on a harm-reduction model than the current race to close encampments and shove people in temporary housing without the permanent supportive housing options in place that are needed for a true Housing First approach.

Harm reduction works, not only for individuals but also for our community. If we want to focus on real solutions, we must be willing to go the distance and move away from satisfying politicians with Band-Aid approaches.

What we need to recognize is that for one, it is not realistic to enforce abstinence on every person as it could actually do more harm than good. Some people need to gradually reduce their substance use and/or get to a place where they can manage it better. Plus, we have to understand that not every person is ready to give up drugs just because we want them to. Thus, when we focus on housing people, we need options. And punishing those who have learned to self-medicate because they have lost insurance, income, their safety nets and trust in people, is simply not working. At the core of a harm reduction approach, regardless of the nuances in the definitions I cited, is the need for us to build trusting relationships. This includes for us to listen to the people we assist and trust that in the end, most of them will know what path they are able to take and sustain.