Thank you to Avi Rudnick, JD, MSW of Chicago House for this guest post!

In the early years of the HIV/AIDS epidemic in the U.S., nearly 100 activists met at the historic Baton Show Lounge to address the dire need for housing for Chicagoans living with AIDS; out of this Chicago House and Social Service Agency was borne as a not-for-profit providing a compassionate response to the disease. Chicago House serves individuals and families who are disenfranchised by HIV/AIDS, LGBTQ marginalization, poverty, homelessness, and/or gender nonconformity. Most of the individuals served have received messages in the past from family and friends that increase shame and stigma regarding behaviors and health status, which can result in a disengagement from services. It was important for Chicago House to choose a service philosophy that helped meet the service recipient where they’re at. Enter harm reduction.

What is harm reduction?

Harm reduction is a client-centered, trauma-informed approach that emphasizes safety and client self-determination. The philosophy dates back to work being done by activists, doctors, programs, and policy-makers in the 1960s and 70s as legal systems all over the globe began to take punitive measures against drugs. An early adopter of the philosophy was the Netherlands who put together commissions assessing whether strict law enforcement was best practice, referring to it as a “balance of harms.” It wasn’t until the 1980s that the collective efforts began to be referred to as harm reduction.

Harm reduction treats the individual as the expert in their own life, service recipients are given the agency to determine whether or how they want to change behavior. While harm reduction does not promote risky behavior, it also does not mandate sobriety as a barometer of success. A concrete example of how this plays out in the real world would be needle exchange programs. Needle exchange programs provide a safe, non-judgmental space for intravenous drug users to exchange their used needles for clean ones. They have been shown to significantly reduce the spread of blood-borne pathogens, such as hepatitis and HIV and, in fact, are associated with increased participation in treatment programs. Instead of focusing energy on the individuals’ sobriety, the programs provide resources to prevent the spread of disease and create a safe space for users. In addition to utilizing harm reduction approaches for addressing substance use, harm reduction is a philosophy that can be applied to many aspects of individual and community life, including, but not limited to: housing, health care, intimate partner violence, and mental health.

Why this philosophy works for Chicago House

Given the individuals served by Chicago House’s marginalized identities, it is not infrequent that one of the earliest and first hurtles is simply earning their trust and building rapport, that is Chicago House’s service providers’ first task. By prioritizing that relationship and putting the individual as the expert in their own life, the service providers help to even out the natural power dynamic that occurs and puts the individual at ease. Together the client and service provider can then explore the individual’s reasons for engaging in high risk behaviors and develop strategies and motivation to engage in safer behaviors (such as engaging in primary care and going on Pre-Exposure Prophylaxis). They inventory the individual’s coping mechanisms and enhance them. Harm reduction supports any positive change, thus putting the individual at ease that they are in a safe space.

Another reason harm reduction makes for a strong service philosophy for the population Chicago House serves is its relationship with trauma-informed care. Most of the clients served by Chicago House and Social Service Agency have experienced some form of trauma in their lives, so it is both fitting and necessary that the agency’s philosophy of care includes a trauma-informed approach to services. Client behavior is considered through the lens of someone who has experienced trauma and is honored as a coping and survival skill, highlighting the clients’ resiliency and ability to adapt which dovetails nicely with harm reduction’s strengths-based approach. Staff members work with clients to establish and maintain a sense of safety and mastery in their environment, something that is often times difficult for individuals with a trauma history, and recognize this as a basic building block for all other interventions.

Implementing harm reduction during service planning

Harm reduction philosophies are infused in the service planning process with clients and work to establish realistic goals regarding housing, health care, income, employment, education, substance use, mental health, etc. Chicago House approaches the creation of service plans with clients as a collaborative process, centering the client as the expert of their own life. While our funders may require that we include certain categories in our service plans, we work with clients on an ongoing basis to develop objectives and strategies to accomplish their goals. For some clients, a goal may be scheduling and attending an appointment with their HIV provider within the next six months, studying for the math portion of the GED exam, or going to the public aid office to apply for the Supplemental Nutrition Assistance Program.

Utilizing a collaborative harm reduction approach allows for changes in life circumstances and for our clients to move through the stages of change without being on the receiving end of shame inducing program requirements that increase fear and the possibility of discharge from programming. If a client does not achieve their goal within the six months outlined in the service plan, case managers use the opportunity to try different interventions, assisting the client in identifying strengths and new possibilities for different goals or a different approach to achieving the existing goal.

Harm reduction-related professional development

Chicago House regularly provides staff with professional development opportunities, such as brown bag lunches. One topic they facilitated recently was Sex Work: Reducing Stigma and Shame. Many of Chicago House’s clients have or are currently engaged in sex work. Instead of asking them to stop or making them feel bad about their choices, providers are being taught about the experience of sex workers so that they are more equipped to support the service recipients.

During this brown bag, staff watched a video of a Ted Talk presented by Juno Mac. She is a sex work activist who fights for sex worker rights and decriminalization of sex work. The discussion was centered on the implications of sex work for specific communities, particularly for trans women of color. Staff reviewed the report, Minority Stress and Sex Work-Understanding Stress and Internalized Stigma by the Sex Workers outreach Program (SWOP) as well as the National Transgender Discrimination Survey, Meaningful Work: Transgender Experiences in the Sex Trade. The brown bag talk wrapped up by reviewing the SWOP guide, Screening 101: Introductory Advice on Why Screening is Important and Some Basic Tips for Avoiding Bad Dates. This screening tool is information that can be directly relayed to the individuals served, providing strategies for reducing harm when engaging in sex work.

Additionally, all new staff members at Chicago House participate in a six-month philosophies of care training series, that includes an in-depth curriculum on harm reduction approaches, with two of the six sessions dedicated to trauma-informed care and motivational interviewing.  All program staff members begin this training program within the first three months of employment for a total 12 hours of training on harm reduction approaches.

How other organizations can integrate harm reduction

• Develop and implement ongoing trainings for program staff and administration on harm reduction and related philosophies, such as trauma-informed care and strengths-based approaches.
• Infuse harm reduction language in all policies and procedures, reassessments, service plans, and psychosocial assessments, ensuring to eliminate language that can increase shame and stigma (i.e. not using the terms “clean” and “dirty” when referring to substance use).
• Eliminate the possibility of discharge or ineligibility based upon substance use, sex work, and/or criminal background by focusing on behavior and not stigmatized labels and identities.

The views, information and opinions expressed herein are those of the author; they do not necessarily reflect those of the Council on Accreditation (COA). COA invites guest authors to contribute to the COA blog due to COA’s confidence in their knowledge on the subject matter and their expertise in their chosen field.

Avi Rudnick

Avi Rudnick, JD, MSW began his time at Chicago House and Social Service Agency as a supportive housing case manager in July 2013. Avi stepped into the role of Director of Scattered-Site Housing in February 2016. Avi also facilitates trainings for program staff on harm reduction, trauma informed-care and motivational interviewing. In addition to his role at Chicago House, Avi has been the coordinator of the monthly Name Change Mobilization at the Transformative Justice Law Project of Illinois since 2012. Prior to working at Chicago House and his involvement with TJLP Avi worked as a public defender in Portland, Oregon.