Wikipedia says that harm reduction is “a range of public health policies designed to reduce the harmful consequences associated with various, sometimes illegal, human behaviors”. Harm reduction, by this definition, often occurs in the context of services for people struggling with addiction. But there are broader applications.
I recently asked what harm reduction means to people in my FB feed. A lot of folks responded right away. Highlights include:
Eliminating stigma, meeting people where they’re at (as opposed to where someone might think they “should” be), loving people where they’re at, acceptance, never denying people their basic rights, decriminalization, pragmatism, dealing with reality, recognizing that we live between ideals, empowering people to make their own decisions, making genuine connections so that people can be honest about themselves and not have to lie in order to access care.
A recurring theme, in community acupuncture, is “not doing diet and lifestyle counseling”. This comes up frequently for few reasons. When you’re treating four to six people an hour, you just don’t have time to tell people what to eat or how to live (even if you were interested in doing that, and most of us aren’t). But because we’re taught in acupuncture school to “front-load the treatment”, i.e. do quite a bit of talking before you actually do the treatment (I explained in an earlier post https://www.pocacoop.com/prick-prod-provoke/post/on-acu-education-gaps-and-pocatech-grads why this is not necessary) there is a considerable amount of deprogramming to be done when transitioning to a community acupuncture practice.
In my mind, this deprogramming requires both some new skills not taught in acupuncture school, and (this part is more difficult for many people) a basic re-orientation towards harm reduction. What we do is harm reduction.
Everyone is going to die. If you work in community acupuncture, i.e. a high-volume practice, it is highly likely that at some point, some of your patients will die. This is a part of what we sign up for with this work.
Sometimes – a lot of the time – people die or get sick or get injured or get chronic illness, not only because of inevitable human frailty, but also because of colossal, preventable injustice. Lack of access to other health care*, to stable housing, to safe working environments, to healthy food, to time for rest, to protection from violence. The care we provide does “reduce the harmful consequences associated with various, sometimes illegal, human behaviors” – but viewed from a social justice standpoint, the harmful consequences are not so much about individual “bad” choices, but about systemic oppression.
Some of the hardest work we do is bearing witness to injustice. This can take a toll on us as practitioners. Vikki Reynolds, an activist, instructor & clinical supervisor based in Vancouver BC, comments “… when the unjust conditions of people’s lives do not improve … we experience our work as shoveling water. We’re working hard, and working harder isn’t working. The smell of a particularly individual incompetence begins to creep in.”
It was Vikki Reynolds who pointed out to me how individualised the dominant narratives about “burnout” are. “Empathic stress disorder” “compassion fatigue” “secondary trauma” “vicarious trauma” are all phrases gesturing at failures on the part of individuals. We are taught to think that if we are burning out, then we need to do better self-care, have better boundaries. It’s no coincidence that this does not challenge the status quo. Self-care is important, but self-care is not enough to offset the context of social injustice. And please, let’s not pathologize open-heartedness.
Vikki’s work is mainly with therapists and social workers, but her work applies very much to community acupuncturists. She says:
“I believe that spiritual pain and isolation are more useful ways to understand the harms helpers suffer in the work than the prescriptive and individual idea of burnout … I believe that spiritual pain is what leads many people to leave this work. Often times, the extremity of pain and oppression suffered by the clients we work alongside, or the ways of being of the clients themselves, are blamed for burning out workers. In my experience, most often it has not been the clients, their ways of being, nor clients’ suffering which therapists and community workers cannot bear, but the contexts of injustice…”
When the hardest part of my work presses on me, one of the ways I deal with the cracks in my heart is by reminding myself that I’m doing harm reduction in the context of capitalism**, and that while it is not enough, it is so much better than nothing, and that I’m not doing this by myself.
The phrase itself, I think, is significant. “Harm reduction” acknowledges that there is harm being done. Our clinics are busy not just because, well, some people are just unhealthy. Would we treat so much repetitive strain injury or plantar fascitis or carpal tunnel syndrome if people didn’t have such constrained choices around working jobs that hurt their bodies? Would we treat so many menstrual disorders and illnesses related to cysts and other growths if our food wasn’t full of weird hormone-imitating plastics and other chemicals? Would we treat so much anxiety and panic disorders and depression if violence was less normalized, if so many of our patients weren’t highly traumatized?
It can be tricky to measure the bad things that don’t happen, because of the work we do, but it’s worth a try. Think about it. The patient with arthritic fingers who doesn’t have to give up painting, because weekly acupuncture keeps the pain and swelling at bay. The patient who doesn’t lose their job, because they’re back on their feet after a back injury in four days instead of six weeks. The relationship that doesn’t fracture, because someone’s anxiety is significantly reduced. The child who doesn’t have to repeat a grade, because their parent has the support they need to stay sober. The patient who doesn’t suicide because their chronic pain is managed better than they’d ever hoped it would be.
Vikki Reynolds says that we’ve an obligation to be witness for each other, to shoulder each other up. That’s exactly what about 45 of us did, sitting in a circle at the recent Trauma & Resilience workshop at POCAFest last weekend. The collective strength and heart of this community of practitioners continues to astound me.
I don’t mean to romanticize anyone’s pain & suffering, nor do I intend to dismiss how hard this work can be. But I think that there might be no limit to what we can witness. That there is nothing wrong with walking through the world with a broken heart. I know I gathered strength from sharing a room with quite a few broken-hearted & whole comrades last Sunday morning.
Do you ever feel as though you’re shoveling water? What helps you, when that happens? What does harm reduction in the context of capitalism mean to you?
*I consider voting as harm reduction as well, since every time I’ve cast a vote, on a municipal, provincial, or federal level, it has been for the less-crappy option. “Politician A is going to suck, but Politician B is actually worse, so off I go to the polls.” (This is much less empowering than working in community acupuncture.)
**While of course there are differences between the Canadian context that I work in, and the situation in the US, it is still important to note that the Canadian health care system is far from perfect, or egalitarian, and that there many “undocumented” people living in Canada who are denied care (https://www.thestar.com/opinion/commentary/2014/02/02/ontario_denies_dignity_in_death.html) and on at least one occasion, the Canadian government has actually withdrawn citizenship from someone born in Canada (https://www.thestar.com/news/canada/2013/09/18/canadianborn_man_faces_deportation.html).