Here is the introduction/talk about safer injection I planned to give in Portland and didn’t get to.
Thanks for coming! My name is Terry Morris. I am really happy to be here.
How many people here- if you wouldn't mind, raising your hand, are at this conference for the first time? How many people have been to a conference once? Twice? Three times? How many folks here work at needle exchanges? How many folks are already talking with participants about safer injection? Anybody here ever sometimes feel inadequate or less informed than you would want to be when having those conversations than you’d like? Anybody here ever struggle with being uncomfortable talking about this stuff sometimes?
I went to my first needle exchange conference in 2001 and came to my first national harm reduction conference in 2002. These conferences are incredible opportunities to meet awesome people and borrow/steal great ideas. There are amazing people in this movement. There are amazing people in this room. On this panel. It is great to be here- with you all.
So, I have this slideshow that I would like to offer you if it could be of use- it is online at www.tspsf.com and if you want me to email it to you so you can edit and change it to suit your needs I would love to send it to you. If you would like to look at it and help me out by making suggestions for improving it- that would be great to.
The slideshow is basically a collection of images and information gathered from websites, organizations, books and people. The harm reduction coalition, Chicago recovery alliance, SFNE/Homeless youth alliance, harm reduction therapy center, Seattle king county health department, tweaker.org, exchange tools from the UK, Edith Springer, Alex Kral, urban health study, Mona Bennett, Fred Johnson, and people at the exchanges in Atlanta and San Francisco who have taught me.
So please take the slideshow- take what you find useful, ignore anything that is not helpful to you. I have used it to invite people to have conversations about injecting.
It can spark conversations about the circulatory system and anatomy, injection technique, the supplies exchanges give out, vein care, abscesses, Hepatitis and HIV prevention, self care, how people learned to inject. It can invite conversation about people's relationship with drugs, managing substance use, managing a run, relationships and dynamics between people around injecting, conversations about the details of an injecting experience- from what your day was like- what your body was like- what you went through that day to get the drugs you will be using, what you did to find yourself the time and setting to do that injection, who you were with, what your plans are for that trip/high, how people get introduced to injecting- their thoughts and feelings about initiating others, peoples experiences with overdose, and alternatives to injecting from choosing another route to substitution therapy.
The slideshow can be used as a group facilitation/workshop tool, one on one, or you can email it to people or give them the link to the website so they can use it as a self guided tool. I have used it to chat people up in alleys and storefronts at exchanges on a laptop or printed out- at indoor needle exchange sites, in vans parked in alleys, and at the AIDS foundation in big rooms for groups from one person to twenty or so people.
So, none of this information is really from me. I sure didn't generate it- I have learned from and borrowed brilliant ideas from many of the amazing people in this movement, from websites, books, podcasts, videos, movies and I learn on a daily basis when I am working- from my teachers in the community-people who use drugs.
Last week in preparation for this talk I walked down to the exchange to ask exchangers what they thought I should say about safer injecting. I asked a few people about where they got their information about safer injection, where they did their learning about it. I noticed a young man, young, good looking, well dressed- coming in with a bunch of big sharps containers and said hello. I told him I was coming to this conference and was wondering if he wouldn't mind talking with me for a few minutes about how people learn about safer injecting and vein care.
ABOUT THE YOUNG GUY I TALKED TO AT THE EXCHANGE:
He told me about himself: during his freshman year of high school he decided he wanted to try every drug out there. He tried weed. He tried cocaine. He tried valium. He tried a number of pills. One day he tired oxycontin. He loved it. When he described it he said “with oxy I was at ease. My worries, doubts concerns- were eased” and he said he could focus on what’s at hand.
The OC experience taught him some things he found valuable about all the worrying he was doing- all the fretting-and how it was basically useless- what he learned getting high- that teaching bled into other parts of life- he found himself mentally more relaxed when he was sober- all that worrying was gone. The downside- the bad part of oxycontin for him- was that the depression he struggled with increased 10x. So there is an AND between those two- not a BUT. We are sort of conditioned to frame things like “this is good- BUT- this is bad” where what might be a more helpful way to frame it is “this is good- AND- this part is bad” Both can be true at the same time- without de-valuing the other.
I asked him HOW DID HE LEARN ABOUT INJECTING: He learned the safety aspects from the internet. “When I decided I wanted to inject I researched on the web.” I asked, “Where did you find helpful information? What sites?” He told me thefix.com was good, readit.com/opiatesand recommended opiophile.com an online forum for opiate users.
I asked “What have your experience been like coming down here to the exchange?” He said, “Well, I feel awkward- I feel detached from everyone else who comes in. I mean, I am from _____ (a very wealthy neighborhood in SF) I am a student at _________ (a prestigious university) I am successful in school. I am an achiever. I feel really different from most of the people that come here. With that my experiences have been really positive. The people here are always friendly.”
I asked what suggestions he would make for us to improve how we do what we do at the site…. Well I don’t have any big suggestions, but….He pointed out the posted flyer-the Warning about the reformulated Opana ER pill that is dangerous. He let me know that the picture of the pill on the flyer is wrong- the new formula with the E on the front is the one that has been causing problems. The pills shown on the flyer are the old version.
This young man did research. And he made a plan with a group of his friends that also wanted to try injecting. They made agreements with each other- they wouldn't share any injection equipment. If any of them when off the chain- and got really too into drugs they would tell that kids parents. They all agreed. They stockpiled backup opiate pills so that if one of the circle of friends had to make a choice between doing something crazy and stupid to get money to buy drugs- this person could have an OC so they wouldn't have to go out and do something sketchy. The group also kept suboxone and narcan handy- they all share a script- one of them has a pain management doctor that he could get OCs from- the idea with the group of friends was “if you ever are considering doing a shady thing for dope you can get an oxy off a friend.”
WHEN I ASKED THE YOUNG MAN about his experiences injecting, how his veins were- he said he had a really hard time injecting and it would take him 20 or 30 minutes to get in a vein. It was frustrating- bloody. And he actually finds himself snorting heroin (he has a good connect) or choosing to swallow a pill more often than not now. Which he was happy with. So I didn't jump in to LETS HELP YOU GET REALLY GOOD at INJECTING so you don’t have to be a bloody mess. I took a step back- respecting his ambivalence about it. Turns out he was returning syringes and picking up for his dealer so he would get a free sack of dope. The syringes weren’t for personal use.
He talked about the stigma around injecting- this is secret stuff. His parents and non using friends have no idea he is using right now. They say things to him about how great it is to see him over drugs-and not using anymore- how healthy he looks etc. and he laughs because he knows he is using and their observations are funny to him. He has to keep it hidden.
When he talked about his DEPRESSION he explained he has dealt with it throughout his teen years. Part of his experimentation with drugs was partly a search to feel less bad. When someone gave him an OC and he took it he loved it.
My conversation with this young man illustrates a few really important things-
people are resourceful,
people anticipate and address problems they might face in very creative ways,
people care about each other,
people are thoughtful and have a lot of self awareness about their relationship with drugs, their mental health, and themselves and take steps to tend to it,
money and self esteem, and family and friendship, and connections to others, and hopes for the future, and resources and a sense of belonging sure can't hurt! they are protective.
people are motivated to take care of themselves.
drugs give things are helpful AND drugs can be harmful. (depression)
Drugs can be teachers- the teachings can have implications that impact our lives- not fretting and freaking out about things- being more relaxed in daily life.
YOUNG INJECTORS are not a monolithic group. They are unique and diverse individuals just like everyone else. When this young men talked about other young people he met at his dealers- he saw them as reckless- not willing to listen to anyone else- and taking a lot of chances- because they are young and think they are invincible.
Learning to inject can be a really rough and messy trial and error experience.
And peoples decision to become proficient at injecting can be very related to how they think they will be able to manage their drug use. This young man gave me the message that he had kind of given up on injecting and chosen to snort or take pills instead. This decision was in part a strategy to continue to keep his drug use manageable.
People think about and take care of the prevention of blood borne viruses!
People often have to lie to their friends and family about drug use. it is a secret. the stigma on it is massive.
People coming to the exchange are often picking up supplies for OTHERS.
While I was talking to this young man I did some noticing… what I was feeling listening to him, what were my impulses, my urges talking to this young man:
What was I struggling with while we talked? Even though I did a buttload of drugs as a kid and wouldn't have listened to anyone tell me otherwise- as a grown middle aged lady these days- if I am honest- generally- I struggle when young people come in to the exchange. it’s my shit. I want to protect them. I want to tell them what to do. Part of me doesn't want them to be shooting drugs.
I worried about his future
I worried about his depression.
I worried about him overdosing and his mom (who i made up in my head) his mom (who has no idea he is using) finding him in his room.
I wanted to help this kid get better technique while i was listening to him talk about the bloody trials and tribulations he was experiencing trying to get a hit when i asked about how his injection sites were- were they sore- did they hurt- any scarring or marks. But when I listened- that might not have been on his agenda. So I had to let it go on mine. He didn't ask.
Recognition that this young man didn't learn from us he is self taught. Our role as syringe providers-to him- we are a spot to get supplies- a friendly exchange- we might NEVER meet his friends, his dealer, the young people he sees at his dealers house.
USER TO USER information, support, and advice is the BEST stuff there is!!! SOME PEOPLE WILL NEVER EVER EVER COME INTO AN EXCHANGE::: what can you do to make it easy for people to get supplies- as many as they need- how can you foster secondary exchange and let people in the community know you value and appreciate their efforts? How can you help people share information between each other to support safer injection?
At an exchange you won't be able to offer what could happen between people using together. Its different to be able to access works at a kitchen table- at a friend’s house, and shoot the shit while you are picking up works (maybe you are fixing up)- in a relaxed comfortable non clinical, (depending) non chaotic place/ relaxed comfortable place to get information, raise concerns, get info and advice.
The best innovations and ideas come from people who use drugs- we can learn a lot from people who come to our services.
If you invite someone at the exchange to sit and talk- OFTEN they DO have TIME and THEY DO WANT TO and they DO APPRECIATE that YOU WANT TO LEARN ABOUT THEM and HOW THEY ARE DOING. Sometimes we assume people want in and out service- and we can miss opportunities engage people in conversation.
I began volunteering with the Atlanta Harm Reduction Center in 2001. The Atlanta Harm Reduction Center is Georgia's only syringe exchange program- Georgia has insanely restrictive syringe access laws- no pharmacy sales without a prescription- and no okay from the local health jurisdiction to do it legally. So in Atlanta when you hand someone a ten pack- you are breaking the law. At one of our sites off duty police officers were paid by local merchants to patrol the neighborhood. It was a gentrifying stretch of blocks that used to be a very busy sex work stroll. The cops would park across the street. They would come over to our outreach van. We hid the syringes in the back seat and put them under bagels in bags when we handed them out.
Just like everyone here- I have my own unique story of how I got into harm reduction and how drugs and drug users fit in my life. I have done most drugs- and I have done a lot of drinking- like most people who drink and use drugs- my relationships with drugs and alcohol never got too out of balance. I never got into trouble with the law, never had to make compromises I didn't like, suffered big consequences, or lost anything I would miss too much behind my drug use.
While I have injected a couple times- I was a tourist- I don't have the personal experience with injecting to teach from. I don't like needles. I have and always have had relationships with people who inject- friends and family-people who I love a lot- who do inject. So basically when I talk to people about injecting I let them know that this is not hard won knowledge- I haven't learned about this stuff from personal experience- I have never dealt the frustration of a missed hit, an abscess, survived an overdose, been dope sick… I have learned by being a nerd- reading up on it- and most importantly listening to people with life experience.
I remember when i first read this book- the guide to getting off right- a safety manual for injection drug users- I got all queasy and grossed out.
If we had time I would have started off by getting to know you all a bit.
I would want to know your name and where you live.
I would like hear about the work or volunteering you do that landed you at this conference
What were you hoping to get out of this session about safer injecting?
I would want to know what kinds of conversations about safer injecting are happening with folks where you work or volunteer. What settings are these conversations happening in?
What kind of safer injection information and resources are available to people?
What tools are you using now- what recommendations would you make about how to invite folks into conversation about safer injection. What has worked for you and your programs?
What gets in the way of having these conversations? Why doesn't more of this happen?
What’s it like to have conversations about safer injecting?
There’s probably a lot of diversity in this room.
How many people here work at an exchange?
I'd also want to ask you in general, how are you doing- doing this work. This harm reduction work.
Before you begin to imagine talking with folks about safer injection take a minute to be with yourself and the context in which you do this work. Let’s meet ourselves where we are at.
I went to this great worship called IN IT FOR THE LONG HAUL about burnout at a harm reduction conference in 2002 facilitated by Stacey Rubin who ran an awesome program for homeless youth in new york city called streetworks.
The workshop was attended by about 40 burnt out do-gooders- outreach workers, needle exchange staff, people who worked at drug treatment programs, drug user activists, and a couple of executive directors.
Stacey asked us about how we sustained our harm reduction work and avoided getting burnt out.
She gave each person 1 minute to talk about what is burning you out in your work- and i want to share some of them
Some things that were burning people out
• death death death. by overdose. violence. illness.
• immense sadness at the losses of wonderful people.
• being the one to notify the family when someone dies because you are the only one there to do it.
• seeing people having recurring relapses, assistance into drug treatment, relapse- over and over with no immediate results
• people dissappearing- losing contact with clients who are arrested/incarcerated. our countries drug laws impact on clients. not helpful. harmful
• the many needs that our systems aren't designed to respond to.
• being sick of working period. anywhere. doing anything.
• not moving on (leaving the job) when its time to leave- because it feels safe. internally feeling ineffective. feeling useless. In your safety zone and being unwilling to take a risk and leave.
• it takes a lot of time to decompress after work- always running- dealing with overdose, death, people in crisis, working at places with high turnover and lacking a sense of teamwork or support
• not being able to ask for help or take support. constantly acting as a support for clients and your co-workers so you can help them do better work and feel better, but not asking for and or receiving help yourself.
• not stopping. never taking a lunch break.
• working on your days off
• isolating. not talking about your stress.
• not having friends/family who understand the work or are compassionate towards drug user, or they just can't deal with hearing horrific stories of loss/suffering/injustices so they can't support you.
• being in NA or AA and having people judge you for working in harm reduction. not being able to get the support you need for your own program/recovery because of harm reduction work/alienated/dogged out for it.
• having friends/family tell you to QUIT because they can't sit with you through the hard stuff and don't understand why you would care about "drug users" and "criminals" in the first place.
Burnout recipes based on agency problems/systems/policies
• board of directors who are not responsive and don't understand the clients served. they don't trust the staff. Everything is political and it’s hard to trust anybody.
• Harmful agency policies/city/state/federal policies that prohibit the front line from getting clines what they need.
• Not getting enough training to work with drug using clients- only one training a year based on harm reduction strategies and approaches- feels like you don't know what you are doing with clients. feeling inadequate and unskilled sucks
• No supportive supervision.
• too much work for one person- not enough time for administrative tasks/reporting requirements and work with clients
• activities that help build relationships with clients are not recognized as good work because they don't fit in with the contract deliverables and your supervisor doesn't understand that those interactions are meaningful and support people to make positive changes to (i.e. if you aren't talking about HIV with someone/doing a recognized 'intervention' you aren't doing your job- this work is not valued.
• Some of the most important work you do helping people who come to services is not measurable.
• Moving from being a grassroots agency to a professional agency.
• rift management v. front line staff
• managers struggling for power and recognition, say they are about serving the people but it seems like they just want to advance their careers
• agency politics
• one for one syringe exchange rules- negative health outcomes for drug users- policy is about allaying non user fears not about drug users health- having to deal with doing what you are not supposed to do (breaking the rules) and sneaking- not being able to be hones about what you do at work because you know it’s right.
• Infighting at agencies- shit talking among agencies. they don't even know who yo kno do work and are advocates for drug user health
• having 2 or more bosses- conflicts-competing needs- too many layers of supervision
• being micro managed
• Balancing work that is client centered when we work at agencies that are public health oriented it is had to maintain integrity and honor contractual obligations sometimes.
• Managing volunteers is challenging, other volunteer opportunity provide immediate rewards and clients will who their gratitude- you get to see immediate results and challenges- this motivates many people to continue to volunteer.
• Working with homeless drug using clients change is not immediate- sometimes they are not thankful. They complain. It can be demoralizing for volunteers who are motivated by gratitude from clients.
• The war on drugs, racism, classics, sexism, homophobia, the prison system.
Stacey had some great advice:
TIPS FOR STAYING IN IT FOR THE LONG HAUL
keep cynicism and hopelessness at bay: don't let the system get you down. or at least not suck the life out altogether. Don’t catastrophize. Don’t be a voice feeding into the drama.
Share your thoughts, feelings, frustrations, joys, pains, especially with colleagues and folks that know the scene.
Learn about yourself. Your challenges, your strengths, your blind spots, your reactions and triggers. Be open to feedback. Notice your emotions, know that it is okay to change and evolve.
THINK "DETACHED LOVING KINDNESS"
Don't obsess on the outcome. Remember that people make their own choices. allow folks to find their own path.
Be flexible and open to new ideas. try things out, step out of your comfort zone. Don't fear failure, we learn from all of our experiences. Use humor, laughter, and beauty in your work.
REMEMBER TO SELF CARE
Tend to your own physical, emotional, and spiritual needs. Take vacations and claim your down time. Do different types of things in order to have a balanced life.
BEARING WITNESS CAN BE A PROFOUND THING
Being present, holding the space, remember, sometimes this is what you do. This is enough.
ABOUT BOUNDARIES: It is a common question for boundaries to come up between counselors and clients/consumers particularly when working in not traditional settings where flexibility, individualized engagement, and a desire to 'meet people where they are at' is the goal.
There is not book that can outline the diverse situations you will find yourself in, nor is there a set answer on how to respond to a particular scenario.
There are the obvious and usually state boundary rules of thumb- no sex- no drinking/drugging, no money exchange between staff and clients. There are also more subtle ways that safe boundaries are at risk of being crossed: becoming over involved in a situation, having too much investment in an outcome, being aggressively directive with suggestions or authority. Boundaries can ALSO be violated when a counselor acts disrespectfully, is UNDER INVOLVED, not showing the care and concert that clients deserve.
When handling the issue of boundaries, your greatest strength will be your innate common sense. Your most trustworthy tools will be your empathy for others and an honest assessment of your own motivations and feelings.
When in doubt, talk to your peers, your colleagues, your supervisors. we learn from each other- but only if we share. We learn from mistakes, but only if we recognizes them.
In preparation for this session I also went to the needle exchange to talk with someone I see regularly who is a great harm reductionist and not burnt out- a woman who does nursing at our site. She is the real deal. Respectful. Down to earth. strait talking. Genuine. And she cares deeply about the people at the site and it shows. I asked her:
What makes you good at what you do?
She says… Constantly struggling with your own judgments. If you are conscious of your judgments- that’s part of the battle. you get into trouble when you are convinced that you are right. No matter what. you have to Believe you don’t know everything. Everyone can teach you. You’ve got something to learn. We all have thoughts about how things should be. you have to be aware of them. You have to see and receive people as people- people with a past. People with a future. People with relationships.
You have to not be pushy. People will show you when they are receptive to alternatives.
So before you think about talking safer injection with folks take some time to turn towards yourself.
Imagine what it will be like to do it.
Have a look at how you feel about having these types of conversations.
Notice your beliefs
Notice your attitudes
Notice your assumptions.
Notice your burning desires. Things that might make you push an agenda- have a predetermined destination- a pitch that you are attached to- anything that might get in the way of being with the person and taking their lead. Notice anything that might make it tough to be a good collaborator.
How do you feel about giving information about how to inject?
How do you feel talking in uncharted territory? None of this information or suggestions are “scientific” and while some practices might make things less dangerous- you really can’t promise “safety” when someone is injecting drugs of unknown content/purity. How is that for you? How do you sit with that?
How do you talk to yourself about it?
Are you ambivalent about talking about some things that might come up? What if someone wants to talk about neck injecting? Or injecting other people? Or shooting pills that are dangerous? Or into an area of that body that has open wounds or ulcers?
What are the connections between what you are talking about with folks and your life (personal history/present/relationships).
Will talking about this stuff trigger you?
What will it be like to surf the emotions that come up for you? Will it make you feel afraid?
Will you see sides of yourself, attitudes you hold- that you might not like so much? Are you up for letting those thoughts just be thoughts?
Are you willing to be compassionate with yourself? Are you good to go approaching yourself with the same kindness you would extend to a participant?
to be imperfect
to fuck up.
To not know everything. To just do the best you can?
Are you willing to respond to what’s happening and go with that flow?
Are you open to learning from and experiencing the person you are with?
I think it’s okay to be transparent if you are struggling. In my experience people who have a lot of experience using drugs can read people from across the street- they are very observant and intuitive- it’s hard to hide things from a lot of them. You don’t have to pretend that something that is worrying you/very concerning/freaking you out doesn’t. But you do want to be aware of how you choose to express your concern… is how you are expressing concern helpful or harmful.
A lot of good outreach workers were at one time or another good sales people or hustlers- worked in shops- customer services- great outreach workers.
Good outreach workers and community organizers generate enthusiasm. The key is sincere enthusiasm- If it is genuine and abundant it is infectious.
In this work- this harm reduction work- we transmit warmth and caring and love. We help people talk about things that are secret. That are shamed. That can be scary.
In conversations reflect the strengths , value, intelligence, and independence of the people/person you are sitting with.
That person may be disempowered. Marginalized. An outsider. Outside routines. Relationships. Economies. Lifestyles. Be with them. Side by side.
All of us (not just people who use drugs or inject drugs) sometimes struggle or waver in our motivation and actions supporting self care. We all struggle with our relationship to ourselves. Self love. Relationship to the world. Where we fit. Belonging. Our own worthiness, value.
I am a person. You are a person to. bingo.
In preparing for today I got really inspired to learn more, improve this slideshow- and think about trying to get together a group of folks in SF to talk about injecting and the different ways we might create some new opportunities to engage folks about safer injection together.
I did a lot of new reading and listened to hours of these podcasts from this conference that happens in England called The conference on safer injecting. I had my own little mini conference- you can find the podcasts and all of these amazing power points on their website- www.exchangetools.org.
I listened to sessions with titles like: understanding skin and wound care, blood borne virus transmission amongst injecting drug users, working with drug dealers, from peer to infinity; engaging pees as partners in needle exchange delivery, groin injecting in the context of speedball and crack injection; using ultrasound as a tool for helping femoral injectors, and one called simply: Neck injecting.
The experience of listening to experts in the field of harm reduction, nurses, researchers, drug user activists and health educators, doctors, surgeons was inspiring. It was moving. It was a little overwhelming. There is so much to learn. There are so many amazing dedicated people willing to teach.
I listened to lots of talks about femoral/groin injecting, deep vein thrombosis, skin and soft tissue infections, how to take care of wounds if you aren't a nurse- understanding what helps abscesses and leg ulcers heal, consequences of vein damage, research into how people who have been injecting and avoided hepatitis c did it- interview with a surgeon who brings a portable ultrasound machine to storefronts and does scans of peoples groins who are femoral injecting to engage them around their health and practices.
the voices of caring beautiful nurses specializing in wound care at exchange sites. The passion of the outreach worker who developed a scoring card she uses to engage people at sites that gives folks an assessment of how much 'harm' they are in based on their practices and motivates people to lower their score, highlighting the fact that often we (and by that I mean me and the program I am part of) don't know very much about the people coming to our sites, where they are injecting, the state of their injection sites, problems they may be having.
The outreach worker who developed the self scoring survey about injecting harm pointed out the many opportunities we are missing. She talked about what we don't ask about. When we don't engage. She talked about how the level of staff/volunteer skill, comfort, interest and ability to engage folks around these issues really matters.
Besides learning so much from the content of the podcasts- I couldn't help but learn some things about how they talked about it- variability in attitudes- sometimes a flippancy when discussing life or death health problems- hints of frustration, despair, judgment, disgust, ideas, stereotypes, attitudes about drug users and ideas about what is important or not important to “ a drug user”.
Also in some cases the underlying emotional content the speaker brought- this parallel story in their talk- subtext of the talk- an attitude of ownership of the bodies of people who use drugs. The expert stance/professional stance. I.e. “I am tending to your body (implication-because you don’t) I have ownership over this wound site, blood vessel, heart valve because I have repaired it- you let me down if you don’t follow through. Do what I say! Look at these consequences! Make changes! Take care!” Very directive.
With the professionalization of harm reduction…Who’s body is it anyways?
In my experience- people who inject are generous with their knowledge- drug users will teach you if you ask, they will help you better see in places where you are blind or nearsighted, and drug users are willing to forgive a lot of dumb questions. Drug users have a lot to teach.
I think what has helped me be a good learner is that i am not afraid to reveal how ignorant I am. I DONT KNOW JACK ABOUT THAT. I AM NOT AN EXPERT. Could you help me better understand this?
I think what has helped me be effective in conversations with people about safer injection and vein care is being upfront with people that what they are getting in me is a very imperfect teacher. And what they are really doing is having a conversation with someone who might share some information- but who is really there to learn about how things work for them.
The non-judgmental open stance piece is pretty crucial, because a lot of what that means for a facilitator is being able to provide accurate nonjudgmental advice no matter what questions somebody might have. That sometimes means knowing where you can't be helpful and instead of pretending you can- communicating about your limitation, saying ‘that’s not something I feel comfortable talking about, or ‘that’s not something I know anything about’ or 'I am not the best person to help with that. Can i help you find someone to help you with that?'
Harm reduction workers need to model harm reduction. When I am talking to a participant or facilitating a group I need to model my own comfort with drug use and injection drug use. Or often, I need to model that I am managing my own discomfort. Because I get my buttons pushed in when people ask me questions that trigger my fear, my judgments, my opinions, my values.
The founder of Aikido said that it’s not that he doesn’t get thrown off balance, its that he comes back to balance very quickly.
I think that’s at the core of harm reduction.
It would be unrealistic to expect that I could never get triggered, that I would never judge. It’s part of the human experience, so it’s about the process of bringing it back and finding your balance.
When I say trigger I mean things that feel bigger than my ability to manage. It could be fear. Anger, judgment, hopelessness.
So you call together a workshop- or you gather together a set of tools to cart to the exchange with you… you do outreach… people show up- maybe you have $ to serve them some food…
Think about the people who will come. What do you think it’s like to come to services where you are?
Think about the mindset of the person who is sitting with you. The group. Who is in the room? What do they have in common? How are they different from each other?
How was it for them to get to the site, office, storefront, workshop, appointment?
What motivated them to come in today?
What’s it like for them to sit with you or be in a group with you? what are they wondering about you?
What kinds of issues are you bringing up for them to reflect on with the questions you are asking?
Are they rested? Hungry? tired? Dope sick?
How is the relationship between you?
Are they relaxed?
Do they feel listened to?
How is it going... helping them listen to each other?
Is it Uncomfortable opening up about things?
Wanting to get their supplies or what they came for and get the heck on?
Did they want to come and eat and go- cool beans!
You may have in any given workshop people who have ambivalent views about injecting and/or drug use in their lives. Depending upon what the topic is- there can be a lot of differences of opinion. Heated discussions can happen. There are often different versions of “facts” about injecting, anatomy, etc. Handle these respectfully and with flexibility.
When you are dealing with issues like injection drug use, its so often a secret, private thing- this might be the first time people have been in a room where a group is talking about these issues.
Some people are facing difficulties in their relationships with drugs, things are going on or wrong with their bodies that are scary, they are getting into situations and running in circles that may be dangerous- all sorts of things might be coming up for people- so you want to try to make people in those situations comfortable enough to sit with their discomfort.
Make enough space for people to explore something new or interesting.
TIPS ON YOUR STANCE while facilitating: humbleness. Genuineness. Concern. Curious. Interested. Role. Assistant. Explorer. Ask permission. No is okay. I don’t know- is good.
What gets in the way of talking with people about safer injection...Barriers to conversations?
Location location. Street based needle exchange sites.
Priorities of folks coming to sites- people are busy. They have things to do.
Your suggestions/information might not be top on that persons list.
TIPS and TRICKS FOR ENGAGING PEOPLE:
At the supply table get curious about how people choose what supplies to take.
If you have a new volunteer- invite exchangers into short conversations with them to help train them.
Ask how they choose a syringe size.
Any open ended questions about the supplies are great “Is it okay if I ask why you prefer the big cotton over the little cotton?”
Observing what needles they choose it is a great way to struck up a conversation. Exchanger: I think i need longs- wait a minute I need 25s" If they are asking for a long wider gauge syringe invite them to talk about what site o their body they are using and offer femoral injection info if they are interested.
have a visual aid- all the points in a picture frame- people will ask about the different sizes and its a great way to get people chatting.
WHATS TOUGH ABOUT ENGAGING PEOPLE IN THESE CONVERSATIONS? initially trying to ask them something to strike up a conversation can feel awkward. Dealing with rejection. Some people are not comfortable asking or opening up these conversations- an exchange worker might be great at giving out supplies- making chit chat- but talking vein care/injection might feel intimidating/awkward/intrusive... some exchangers aren't comfortable talking about it. Asking questions or striking up conversation about it in a public space like the exchange can take people off guard.
Exchange volunteers and staff sometimes assume people are in more of a hurry than they are. Often people are VERY WILLING to slow down and chat and OPEN to talking about injecting.
THINK ABOUT WHERE YOU WILL BE DOING THIS: THE SETTING:
Where do you want to do this talking? Not everyone wants to linger at a syringe exchange- many people will never come in your doors at all. There are A LOT of reasons people might not come into a site or want to linger at a site. Might not want to run into people they know. Might fear for their privacy. Job. Housing. Spot at the clean and sober living community. Might owe somebody money or dope. Might be dopesick. Might be sick, sleep deprived, hungry. Might not be comfortable in the neighborhood- the other folks at the exchange. The agency where you do it. What’s it like for people to come there? Groups might be rough for people.
Options are good- make the info accessible in as many ways as you can- on the fly grab and go info, on the web, drop in times so people can make it when they make it, at syringe exchange sites.
HOW DO YOU LISTEN? HOW DO YOU HELP MOVE THE DISCUSSION?
What kinds of things do you learn about folks over the course of your conversation or group?
Notice the strengths. Practices that they undertake that support health and safety
Invite them to talk about the mechanics of how they get it done/the details/the story of it. Telling your story can help you figure things out. Telling your story can help you imagine new options and wonder if things can move and change in ways that weren’t obvious (or examined) before. i.e. so when you were telling me about the fact that you limit your run to 2 days and manage to eat and drink water while you are partying- it made me wonder-because I talk to some people who have a hard time with some of that- how do YOU DO THAT? Notice and support self efficacy, creativity, determination, self care.
What do you wish you could do more of or do more safely?
When you get high- how easy or hard is it to get a hit?
Main things to keep in mind:
EVERY INJECTION IS UNIQUE
Just because something happened or went down this way last time- doesn’t mean it will be the same the next time.
Access to syringes- so people have the option of using a new one EVERY TIME
· New pointy tip- backloading.
· Making it to the exchange- making a plan
· Stockpiling! (get more than you need at sites. Add an extra site in every week)
· Inviting people to look at barriers to getting clean works regularly and places where they have choice or not. What gets in the way? When do you run out or find you are in a spot without the supplies you would ideally have? How does that happen?
· Respect and invite people to talk about the Reasons NOT to have supplies on them… (homeless, probation/parole, privacy- people around them might not want them injecting- housing situations might not allow it- no tolerance for drug use at shelters- metal detectors etc etc.)
· Feelings about using intravenously- some people might be ambivalent- not wanting to continue injecting (or using) and so don’t want to keep them on them.
· Hard to make it to places- homeless people are busy! Drug users are busy!
· Pharmacy sales- what’s it like to go there. Do they have the $. What is the experience of purchasing at a pharmacy like? are they sold the kind they are looking for?
· Stuff lost/stolen- not safe.
· Relationships. Communication. Dynamics. (asking/telling/ Speaking up/asserting yourself/laying down the way things will work best for you- can be tough)
· Setting. Sexually charged with strangers- v. with a long time friend or partner.
· Supplies- adequate.
· Knowledge- transmission. Surfaces. All the items- cookers/cotton/water/tourniquests/rigs
· Hitting someone else or being hit by someone else. COTTON BALLS ROCK.
· Emotions/jones- fuck its. I am dope sick.
· Knowing your HIV and/or HCV status
· Hep A/B vaccinations and STI prevention/treatment