What that means is joining the person who "uses" in a way in which you can help him/her to continue to drink alcohol or use drugs, but in a way in which it will cause the least amount of harm to that individual, and to those around them. The concept's primary focus is reducing the risk of spreading HIV, therefore it's goal is not to simply allow substance users to indiscriminately use drugs, it is to stop the spread of HIV through both sexual practices as well as substance using behaviors such as IV drug use. It's easiest to understand this concept if we can accept that there are some people whose lives starting in childhood were so horrific that they may never be able to get off drugs. They may have had parents who abused them physically and sexually and had their own issues such as chronic mental illness or homelessness and substance use, which was then past on. And now, as adults, these individuals may never be able to get off drugs. So again, the goal of Harm Reduction is not to encourage their drug use, but to help these individuals cause the least amount of harm to themselves and to those they encounter, when it comes to substances and HIV.

The original Merseyside Model (Parry & Newcombe,1988) conceptualizes harm reduction in the following key principles: HIV takes priority over drug prevention and drug treatment; abstinence should not be the only goal of services to drug users because it excludes a large proportion of the people who are committed to long-term drug use; abstinence should be conceptualized as the final goal in a series of harm reduction objectives, objectives which serve as "safety nets" to protect drug users from serious harm; and, the most effective way of getting people to minimize the harmful effects of their drug use is to provide user-friendly services which attract them into contact and empower them to change their behavior toward a suitable intermediate objective. At first this idea sounds radical, but when you think about it, Harm Reduction is a concept that has been around for quite some time. The expression, which most readily comes to mind, is the phrase "don't drink and drive."  We can easily comprehend that no one is telling  anyone else not to drink, however, they are reminding us that if we are going to drink, don't get behind the wheel of a car where we could possibly harm ourselves or someone else. If you think about it, the entire notion of safer sex education is based on Harm Reduction; if you're going to have anal sex, use a condom;  if you are going to inject crystal, don't share needles; if you can't kick Heroin, try Methadone Maintenance, again as a method to reduce the spread of HIV.  We can see now how an idea that may have sounded a bit radical at first (allowing people to use and in some cases possibly even abuse substances) is not such a radical concept after all. Dr. Westermeyer further goes on to pose that the approach to the substance user should not be one such as "Here is what you must do," but more along the lines of "What can I do to help you?" We can see that the second approach is a compassionate one which meets the needs of the individual where "they're at."

This is a more compassionate than traditional approach for the individual not ready for a treatment facility, an intervention or recovery. What this approach also creates is an environment where the individual is not only taking responsibility for their substance use, but is possibly taking a first step toward sobriety as well. Harm Reduction is sometimes the only way to assist an individual unable to move toward sobriety. It's important to remember that interventions involving Harm Reduction are not intended to encourage drug or alcohol use or abuse, but simply intended to keep the substance user and those around him safe.

According to the Harm Reduction Coalition, Principles of Harm Reduction (New York, NY), some key principles include:

1. Ensuring that drug users have a real voice in the programs and policies designed to serve them and seeks to strengthen the capacity of people who use drugs to reduce the harm associated with their drug use.
2. Recognizing that the realities of poverty class, racism, social isolation, past trauma and other inequalities affect both people's vulnerability to and capacity for effectively dealing with drug-related harm.
3. Does not attempt to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use.

In the HRC Harm Reduction Communication (fall 1997) article Harm Reduction: The Case Management Connection, some very important questions are raised for those of us working in agency settings. Questions such as: Can we as professionals be both faithful to the standards of our profession and still be helpful to our drug using clients who refuse to stop using? Can we ethically deny drug users services (such as case management and housing) based on long standing theories or common beliefs about substance users? And, whose goals are we talking about? Can we base our interventions on contracts made with our substance using clients that are established by the client, rather than "on behalf of the client?" These are some very deep and challenging questions for many of us as providers of services to substance users.

Like Dr. Westermeyer, Catherine Lyons, a nurse practitioner at the San Francisco General Hospital AIDS clinic writes in her article Competency, "Compliance" & Contracting: Using Harm Reduction to Engage HIV+ Drug Users in Medical Services, "A lot of people hear Harm Reduction and what they think you're talking about is giving people what they want. They don't see it as meeting people where they're at and working with them." She goes on to remind us that "a person's medical situation is not, first and foremost, their most pressing concern, and that a social worker, outreach worker, drug counselor or friend may be integral in terms of dealing with that person." LAMP (Los Angeles Men's Place) located in Los Angeles's skid row area has a Harm Reduction Multi-Diagnosed Program for adults diagnosed with mental illness. In its August 1997 Monthly Newsletter LAMP describes Harm Reduction's main concept as "accepting people at whatever stage of recovery they are at, in any given moment in time." And, implores that "we must realize that absolutely anything that helps move a person forward on a continuum of positive and healthy living must be good."

So as we deal with clients, who may not be ready or willing to approach abstinence, we now have some tools to give that individual. For instance, explore with the crystal-injecting client if it might not be safer to snort it instead. If this isn't possible educate him/her on where to exchange dirty (used) needles for clean ones. Share information you hear in the media, like the reports that the interaction between Viagra and poppers can be deadly.   Similar information has been reported on the interaction between the protease inhibitor Norvir (ritonavir) and Ecstasy. Educate the HIV+ client on tips such as if they smoke a little pot, they should "zap" if for a minute in the microwave to kill off fungi (like asperigellis) which can lead to the opportunistic infection cryptococcal meningitis. These may sound like very small steps, but if you take them, not only would you be helping a client to cause himself (and others) less harm, you may even be saving his life.

Anthony Zimbardi, PsyD, MFT is coordinator of HIV Mental Health Services at Tarzana Treatment Center and is in private practice in the Hollywood Hills/Studio City area. He has also served on the LAGPA Board of Directors for several years. He can be reached at (323) 851-1304 or AZpsyD@aol.com

This article is the first in a series being authored by Dr. Zimbardi concerning the clinician's response to addictions in the gay, lesbian, and bisexual community. In the next issue, he will be joined by Rob Weiss, LCSW, CAS, who will author an article addressing his clinical experience as Clinical Director of the Sexual Recovery Institute in Los Angeles.