Meeting Clients "Where They Are"
An Interview With Don McVinney of the Harm Reduction Coalition
Over the past two decades, harm reduction has emerged as one of the most positive social contributions made by the fight against HIV and AIDS. For most of those two decades, Don McVinney has advocated and practiced harm reduction strategies in the HIV/AIDS community. Today, McVinney is Director of Training at the Harm Reduction Training Institute, a division of Manhattan's Harm Reduction Coalition. Recently, Body Positive's David Pratt spoke with McVinney about the meaning of harm reduction, and its contributions to the continuing fight against HIV and AIDS.
Body Positive: How did you become involved in the harm reduction movement?
Don McVinney: The first time I heard of harm reduction, I was working for AIDS-Related Community Services, which provides AIDS education and counseling to seven counties in the Hudson region. At that time, in the late eighties, the population we served was shifting from gay men to injection drug users. I started a chemical dependency support group at ARCS, and later, as a consultant at GMHC, I worked with a woman, Edith Springer, who had brought the concept of harm reduction from the UK to the United States.
BP: What did you learn from her?
McVinney: Like many people, my training on substance use was abstinence-based. Edith had a different perspective: if someone's injecting drugs it's almost unethical, particularly in the face of HIV and AIDS, to insist they abstain before they get services. Rather, it made sense to use the same risk reduction strategies with injection drug users that had been used in STD prevention. If a client said, "I want to have sex, I just don't want to get STDs," harm reductionists would say, "Well, there are strategies, like using condoms." Harm reduction with substances uses a similar strategy. If a person says they're committed to stopping drug use, but has not necessarily stopped yet, you'd still provide services equitably.
BP: Tell me about the abstinence-based interventions that preceded harm reduction.
McVinney: There are many theories about what causes addiction. Harm reductionists say substance use occurs along a continuum; some people never use; some people experiment; some start using certain drugs more regularly, and some end up bingeing. There are clinical criteria for substance abuse or dependence, for addiction. Theories abound about who has the potential to develop addiction.
Since the nineteenth century, the moral theory had been popular; it still is in some areas. It says addiction is a moral failure. The intervention is either moral redemption, or punishment for being morally weak. Criminal justice intervention follows from moral theory. Psychoanalytic theory was popular in the 1930s; it said there were underlying psychological problems that people were self-medicating.
The disease theory emerged in the '50s in response to inhumane treatment of addicts. They were thrown in jails and died withdrawing from alcohol or drugs. The medical community said addicts have a disease, the intervention should be hospital-based -- clinics and rehabs. Most providers today would say addiction is multifactorial, that a number of factors contribute to it.
In response, harm reduction, as an intervention, is what I'd call "metatheoretical" or "transtheoretical": it doesn't necessarily favor or eliminate any theories. There may be moral or biological or behavioral factors. Harm reduction says it's less important to focus on the causes of addiction, than to work in the present with the individual who's using, and to reduce the harm. If you uncover underlying causes, great. But that's not the primary goal. That's different than most treatment programs, which say, let's talk about why you started using, figure out what the factors are. Harm reduction says, you can do that work as you focus on reducing drug-related harm.
BP: How does harm reduction relate to 12-step recovery?
McVinney: Most people in the harm reduction movement are involved in 12-step programs. People who have struggled to overcome their own addictions understand how difficult it is for people to quit using. I think 12-step programs are aligned with harm reduction because the only requirement for membership is the desire to stop. You don't necessarily have to quit before you go. In 12-step programs, what they want is for people ultimately to be able to stop using, but not necessarily "for the rest of your life." It's "one day at a time." So if it takes six months to get there, a 12-step fellowship would say, fine. They say, "Keep coming back, it works if you work it." You may not be able to do it today, but if you keep coming back, you may succeed. And I'm talking about the substance-related 12-step fellowships -- AA, Cocaine Anonymous and so on. Some of the other fellowships are even more harm reduction-oriented. For example, Overeaters Anonymous or Sexual Compulsives Anonymous ...
BP: Because you can't stop eating ...
McVinney: ... and most people don't want to stop having sex. But they want to do it in a way that's not compulsive. So OA's eating plans, or what SCA calls sexual recovery plans, will of course involve eating or having sex, but in ways that are not compulsive. Those are harm reduction strategies. So in some ways, the 12-step fellowships are based on harm reduction, not abstinence models.
BP: What do harm reductionists say about abstinence?
McVinney: Abstinence is an excellent form of harm reduction, because it eliminates any potential for harm. Abstinence is absolutely consistent with harm reduction. We just don't consider it the only way. And it may not be what the client is asking for. For example, there are housing programs for people with HIV and AIDS in New York City that use harm reduction models. A client, an active user, comes in and says, "I want housing." They don't say, "I want a drug treatment program." The housing program worker, using principles of harm reduction, says, "We'll help you find housing -- and while we're getting that stabilized, we'll help you address and hopefully eliminate your drug use." You want them to address the drug use, but you don't withhold or stop the services.
BP: Now, the reverse is not true for those with an abstinence-only perspective, is it?
McVinney: No. If the client goes to a mental health clinic, the provider would say, "Stop using drugs, and then we'll provide services." Same with housing. People are told, "You can't drink or use drugs while you're here. If you do, you'll be kicked out. When you're clean, come back for services." Abstinence-only providers say drug use must be eliminated before services can happen. Harm reduction is the opposite.
BP: Sounds like abstinence-based people say, "You are your addiction." Whereas 12-step groups emphasize, "You are not your addiction."
McVinney: Correct. Historically, in the United States, they said the person who develops alcoholism or becomes addicted to drugs is bad. They locate the problem in the person. That's the moral perspective, used by the criminal justice system. They incarcerate users and addicts for being bad. Then during Prohibition, they said it wasn't the person, it was the drug, alcohol, that was bad. So they made the sale and consumption of alcohol illegal, which was a horrible failure.
BP: Whereas harm reduction ... ?
McVinney: ... locates the problem in the relationship between the person and the drug, because lots of people use substances and don't do so problematically.
BP: I want to talk about harm reduction more in relation to HIV and AIDS. You were "present at the creation" when harm reduction entered the war against HIV and AIDS ...
McVinney: Harm reduction completely emerged from the HIV/AIDS epidemic. Early on we guessed it was a virus, transmitted sexually and blood-to-blood. We believed that because injection drug users were being diagnosed with AIDS. This was confirmed when the virus was isolated in '83. The first model of intervention to use harm reduction theory was needle exchange -- getting injection drug users to use clean syringes, then exchange them for more clean ones. There were also needle distribution programs: you bought syringes at a pharmacy and didn't have to bring them back. These strategies completely emerged from the HIV/AIDS epidemic.
BP: Then these strategies could be applied to alcohol, drugs, sexual behavior and other behaviors that put people at risk of infection or weakened their immune systems.
McVinney: Yes, harm reduction made sense in targeting other behavior changes. If you wanted to reduce drug-related harm, or reduce the risk of an STD or HIV, you tried to get someone to modify their behavior, if not radically change it. Most people don't want to stop having sex, but they want to have safer sex. We don't say, "You shouldn't have sex," although that's a choice we would support. We are not erotiphobic. We know people have sex. It's pragmatic. People have sex, and there are ways to reduce the harm, including condoms or latex dams.
The same with drugs. We acknowledge that there are people who use drugs, who inject them, and there are ways to get them to modify their behavior, so if they choose to continue, they can do it more safely. Those kinds of protocols were part of the original harm reduction models. Then people realized it made sense to apply these principles to other substances. It's about trying to get clients to change incrementally. That's easier than to get them to stop completely. You say to clients, "Are there ways you could use drugs that would cause fewer harms?" For binge-drinking high school and college students, for example, we say, since young people do consume alcohol -- and it seems binge drinking has increased since they raised the drinking age to 21 -- perhaps there are strategies to get them to modify their consumption.
BP: What are some of them?
McVinney: Well, designated drivers, and some colleges and universities have vans pick people up and take them to events where there's going to be alcohol. In bars they use plastic glasses so people don't harm themselves with glass. They train food servers and bartenders to recognize when people have had too much. Another strategy for the people themselves -- and this may sound controversial, but it's effective -- instead of saying, "Don't drink," say, "If you're going to drink, is it possible to have a six-pack, instead of a case of beer?" Work with the client to see if they can do that.
BP: It seems as though much of the progress that's been made, especially social progress, especially with AIDS, has been due to harm reduction. Lives have been saved, and there's a different world view than there was twenty years ago.
McVinney: Absolutely. There are high correlations between substance use and HIV risk factors. Studies have found that, even when people have been educated on condom use and have condoms in their possession, if they've had several drinks, they're less likely to use them. And there are connections between HIV risk behavior and other drugs. There's also evidence that alcohol and drugs compromise the immune systems of people already infected, cocaine being one of the most well researched. There are also subcultures that use certain drugs in certain contexts.
So some harm reduction strategies are very specialized. There are harm reduction strategies for people who use certain drugs at circuit parties and raves such as Ecstasy, Special K, and GHB. By now, most people know that, if you're going to take Ecstasy, you should drink water, not alcohol. People may not equate that with harm reduction, but it's a harm reduction strategy. Then there's the methamphetamine sex club population. That's a different subculture, and the intervention strategies are different. So our strategies are more various and more sophisticated than in the early days of needle exchange.
BP: It sounds as though something counter-intuitive may happen: by acknowledging that the behaviors are going on, reduction/elimination of behaviors will happen more certainly than if the only choice were abstinence ...
McVinney: Right. The abstinence message just doesn't work ...
BP: Why not?
McVinney: A simple solution to a complicated issue never succeeds. Answering "Just Say No" to a complicated question like why people use drugs in the first place won't work. If you further complicate drug use with sexual behavior, or human behavior generally, sex or dancing or socializing, simple solutions won't work.
"Just Say No" may be effective if you're doing primary prevention. If you're telling young children who haven't started, then it's a wonderful message. But many people we work with already engage in these behaviors. Telling them not to do it when they're already doing it is a failed message, and harm reduction aims to be supportive. If people hear, "Stop doing it," they might not even talk to you. So you send a more supportive message: "I'm not telling you to stop, I just want to listen to what's going on. And maybe I can help you to modify or reduce the harms associated with your drug use or sexual risk behavior."
People go out to dance clubs and circuit parties for a reason, and many will use substances while they're there. If you're going and you might use drugs, there are strategies you can use to reduce the harm from drugs or other factors that will make you have a better time and that you won't regret six months from now.
BP: Something that people may be in denial about -- the regret six months down the road.
McVinney: Very true. For various political reasons, people have tried to minimize the fact that drugs and alcohol do cause harm. The first word in "harm reduction" is "harm." We acknowledge that substances can cause enormous harms to the individual and the community. So we find pragmatic strategies to reduce the harms. Most people when they go to a circuit party aren't thinking, "Let me end up Monday morning in St. Vincent's emergency room." They just want to have a good time. We say, "If you want to have a good time, there are ways to have it without causing so much harm."
BP: What do you see as the future of harm reduction, what it's poised to do now, particularly in the HIV community?
McVinney: We must reinforce what we already know about how people change behaviors incrementally. We have a history of over twenty years in the HIV/AIDS epidemic. Harm reduction emerged as a profound shift away from older models of intervention. It took from 1935, when AA started, until the 1980s, when 12-step meetings proliferated, for harm reduction to become popular. Today it's one of the most popular approaches, because it's effective. You can engage people and keep them engaged by working with them where they are, instead of mandating that they change the behavior before they get services. The future is in building on what we know works, and on disseminating some of the models, what is called "technology transfer." We must get information out, help other agencies to use harm reduction and not be afraid of it. There's a lot of misinformation about harm reduction.
BP: What are the most common myths?
McVinney: The word is often that we "condone" alcohol or drug use, which is not true. We accept the fact that there are people who use. It's not condoning, it's meeting people where they are. There's also the perception that harm reduction does not embrace abstinence. I like to say that, if you're trying to reduce drug-related harm, or behaviors associated with drug use, you're also trying to promote health. Harm reduction is the flip side of health promotion. And I think that message needs to be embraced more widely.
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This article was provided by Body Positive. It is a part of the publication Body Positive.