What is "Harm Reduction"?


Here in San Francisco, and across the U.S. and around the globe, alcohol and other drug use fuels the HIV epidemic. At San Francisco AIDS Foundation, we’re doing something about it—and we’re doing it in a unique way that offers dignity and creates results for our clients.

Our family of substance use treatment programs, the Stonewall Project, recognizes that people’s lives are complicated and that every person who walks through our doors deserves respect and a warm welcome. Stonewall offers a treatment partnership, individually tailored to address each participant’s goals and needs wherever they are in their experience with alcohol and drugs. It’s an innovative, proven approach called “harm reduction,” and it’s helping our clients make amazing changes in their lives. 

We sat down with Michael Discepola, director of the Stonewall Project, to hear how harm reduction offers unique hope to the people we serve.

What exactly is “harm reduction”?

What we mean when we say “harm reduction” is basically any positive step in a direction for improved health and wellness. That can mean that somebody who is using a lot of drugs or alcohol starts drinking more water or getting better nutrition. It can mean the difference between someone working their life so they can be stably housed, versus having a drug or alcohol problem and being on the street.

Harm reduction may sound very foreign as a concept, but when you look around, you see people making these decisions all the time; for instance, they’ll have a couple glasses of wine, but they’ll have a glass of water in between. People implement harm reduction in many ways.

How do you put harm reduction to work at the Stonewall Project?

The philosophy of harm reduction as a program is that everyone is welcome, no matter what place they’re in, no matter how challenging their life is, no matter how sick they are. It’s a client-centered, person-centered approach that meets people exactly where they are.

People feel so much shame about their use of drugs and alcohol and what happened in their lives during that period of time; just to be treated like a human being is an enormous intervention in itself. It really changes people’s lives. People begin to realize, “Wow, I can do something else. I have options.”

At Stonewall, we have different treatment tracks for people who want to be fully abstinent from all drugs and alcohol, or be partially abstinent, or be able to manage their use. We try to figure out where someone is on that continuum first: “What is it that you want to do related to your use of drugs or alcohol?” The reality is that it’s not always best—although it can work for some people—to stop cold turkey.

Why is that?

People have a lot of issues and traumas that bring them to whatever place they are in their lives—issues around sexual orientation, or experience of trauma and abuse, depression, loneliness, isolation, shame. Some individuals grow up stigmatized and are treated badly or get thrown out of their families. And some people slowly start coping though drugs or alcohol, and that becomes problematic for them at certain points in time.

But for someone who’s been struggling with substance use as a way of coping with these things, taking the drug or alcohol away without helping them deal with the problems that led to the substance use in the first place is not very humane.

For nearly 13 years, harm reduction has been the official policy of the substance abuse and mental health division of the Department of Public Health here in San Francisco. The city’s philosophy is that “any door is the right door.” If someone comes in to a program—even an abstinence-based program—and has a slip, they should not be thrown out.

How did you get involved with this work?

The reason I started doing this work almost 20 years ago now is because my focus—and the focus of Stonewall—has always been looking at drug and alcohol issues and other psychosocial issues that put people at risk for HIV infection or transmission. Drug and alcohol use is one of the primary drivers of HIV infection and transmission, so starting there makes perfect sense.

There are always goals around sexual health and HIV on everyone’s treatment plan with Stonewall. It may start as a simple thing: Maybe you haven’t been tested for HIV in ten years, so let’s think about when we could get that test done. At Stonewall, we work with lots of people who already have HIV, so we look at that first and say, “Do you have healthcare? Depending on what your lab results look like, is it the right time for you to look at medications? And what would that mean, in terms of your own health, and also in terms of your possibility of transmitting HIV to someone else?”

How do Stonewall participants themselves respond to harm reduction?

I think people are surprised when they see how we actually put into practice what we talk about, and they see how powerful it can be in their lives. I think that level of personal commitment on our part sometimes is surprising for people in a really good way. They’re feel like, “I fit here. People care about me.”

To change your relationship with drugs and alcohol on the level that some of our participants have is really hard work, and I think harm reduction really honors that fact. At Stonewall, we make it clear with our participants and clients that this is a partnership: “You’re going to have to do the hard work. We’ll be here for you, but this is about work that you’re doing, and we’ll help you through it.”

And we celebrate people’s successes. We’ve had people go back to school. We’ve had people go back to work. We’ve had people who were homeless for 20 years who have gotten housing. It’s an inspiration to see people reach their goals.

One of the kernels of our work is that we hold hope for people until they can hold hope for themselves. And the reality is, we believe that there’s hope for everybody.

To learn more about what the Stonewall Project offers to our community—including more than 20 groups and individual walk-in services every day of the week for people in need—visit www.stonewallsf.org.

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