Is Harm Reduction Enabling?
In our field we talk frequently about applying harm reduction to our practices. There are a range of strategies that can be employed, from making sure people have safe storage of their alcohol, drugs and related works to provision of clean needles, pipes and screens; from education and focused conversations on change in use to safe injection sites; from managed alcohol programs to workshops. Even though many of us employ harm reduction strategies in our everyday life (wearing a seat belt while in a car, using a crosswalk to get across the street, wearing a helmet when on a bicycle) the thought of employing harm reduction strategies to people who use substances is still often seen as taboo. Erroneously people think it is enabling, an attempt to legalize substances, or even encourages use.
When wrongly applied, maybe some of these sentiments creep into harm reduction practices when they should not. I would argue that some of the critiques of harm reduction can be valid when harm reduction is misinterpreted and applied incorrectly. For example, I have seen practices that may be better described as harm maintenance rather than harm reduction, and I have witnessed conversations between helping professionals and people who use substances as enabling. But thinking that these shortcomings are widespread is not true. There is no point giving up on harm reduction just because it is sometimes practiced wrong. Let’s face it – many people in our industry are asked to practice harm reduction with the people they support without having ever been trained on harm reduction.
I like the way that the Centre for Addiction and Mental Health responds to suggestions that harm reduction is enabling:
…by respecting these choices and being available to deal with their consequences, the therapist intentionally strengthens the therapeutic alliance. Rather than seeing this as enabling the client to keep harming himself, the therapist understands that he or she cannot realistically prevent a client from making particular choices at the given moment. But by keeping the door open and helping to ameliorate adverse consequences when they occur, the clinician can strengthen the motivation of the client to behave in a less harmful way, and facilitate their engagement in further treatment when the client is ready to move closer to a less harmful pattern of use or abstinence.
In very practical ways, harm reduction is about truly meeting people where they are at, with radical acceptance of the choices they are making in their own life. Good rapport in present reality leads to opportunity for reduction in harm in the future. For every organization that claims to be person-centered, non-judgmental and trauma-informed, practicing harm reduction is an extension of all three of those sentiments.
Harm reduction is a very pragmatic approach to working with people who use substances. I have heard it described as, “It ain’t what’s pretty; it’s what works.” The truth is, substance use in various forms, is part of written and oral history for many cultures. While the drugs may be ever changing and new, drug use is not. We need a range of approaches to respond to drug and alcohol use – especially problematic use – rather than a one-size-fits-all approach. Harm reduction should always be one of the options for people that experience homelessness given the higher propensity of people who are homeless that use alcohol or other drugs. In so doing, we are being responsive to real, in the moment needs. That type of engagement is practically required of us, not an exercise in enabling.
While cessation and abstinence are a choice for some, I reject the notion that we will ever have a drug-free society. I love pulling data from the SAMHSA Behavioral Health Barometer when working with American communities. It clearly demonstrates time and again that slightly less than 10% of the population of any given State has problematic alcohol use and under 5% have problematic use of other drugs – and in both instances, the majority of people in the community receive no treatment or counselling for their problematic use. Closer to home, the Policy Lab at UCLA has analyzed tens of thousands of VI-SPDAT records and found that 51% of the unsheltered homeless population state drugs or alcohol were one of the reasons they lost their housing, and 50% believe their drug or alcohol use limits their ability to be housed. Rather than thinking a treatment or enforcement approach is going to help all of these individuals achieve sobriety, it seems practical to me that harm reduction is the vehicle by which more people will find access to housing and learn to stay housed while also using substances.