Soap, soup and harm reduction

1
Soap, soup and harm reduction

• Everyday management of Finnish harm reduction
  policies.
• Riikka Perälä, M.Soc.Sc.
• Finnish Foundation for Alcohol Research/Dept.
  Sociology, University of Helsinki

2
Outline

• 1 Introduction and Background
• 2 Finnish Experience
• 3 Themes Today
• 4 Analysis, harm reduction and
  client-centerdness as practical accomplishments,
  needle exchange and other (drug) treatment
  services, consequences of needle exchange
• Conclusions

3
Introduction and Background

• Ongoing PhD-study, department of Sociology,
  University of Helsinki
• Harm reduction and needle exchange as part of
  Finnish drug treatment system and welfare policy
• Ethnographical method what is going in here?
  What is new? What is different?
• Data fieldnotes, interviews, document material
  altogether one year on the field

4
Levels of Analysis

• 1) Needle exchange and the drug using individual
  (e.g. changes in behaviour and identity)
• 2) Needle exchange and the operation of the drug
  treatment and other welfare services
• 3) Needle exchange and the ideological premises
  of Nordic welfare states
• Needle exchange as a window to different
  processes taking place in the society

5
The case

• Health-counselling services for intravenous drug
  users
• Work started at 1997 in Helsinki
• Year 1997-2004
• -clients 500 -gt 10 400
• -visits 2200 -gt 83 400
• -changed needles and syringes
• 3100 -gt 1,8 million
• -1 -gt 24 facilities throughout the country

6
continues

• Rapid decline in HIV-infections after an epidemic
  in 1998
• Year 2002 NE as part of official subtance abuse
  treatment system special care unit of
  out-patient care
• Professionalisation of harm reduction work (see
  e.g. Tammi 2004)
• National succes story

7
The Case

• Three services situated in the Helsinki
  metropolitan area (Helsinki, Espoo, Vantaa)
• Needle exchange, health counselling,
  vaccinations, testing, outreach work and peer
  work
• Ap. 80-100 clients per day
• Open from 12-16 every day
• Multiprofessional staff, altogether 16 plus the
  executive
• organisations from the third sector, yearly
  funding from municipalities
• Harm reduction, client-centerdness and low
  threshold as guiding principals

8
Number of problem drug users

• Est. 16.000-21.000 (2005)
• Concentrated to the metropolitan area (0,7-1,1
  of the population)
• in the whole country 0,4-0,6 of the population
• Population in Finland 5.3 million
• In Helsinki 562 570 residents

9
Themes Today

• 1) What are harm reduction and client-centerdness
  in practise?
• 2) Health counselling services role and position
  in the Finnish drug treatment system
• Consequences of health-counselling (both
  individual and the level of drug treatment
  system)

10
Aspects of client-centerdness

• Revolving door mentality
• Flexibility and time as important
• Concentration on face-work (Im okey, youre
  okay)
• Importance of institutional space
• No fixed boundaries and rules negotiated order
• No visible hierarchies and signs of authority
• Thick relations between the workers and the
  clients

11
Extract 1, note from fielddiary, june 2003

• It is possible for the clients to spend time in
  the facilities, all day even, if they wish. Some
  of the clients read papers, some go through
  different leafleats and some just hang around
  while drinking coffee and eating cookies. At
  first it strikes as unprofessional to me that
  workers dont necasserily take that much contact
  to the clients. However, slowly I began to
  understand the meaning of this kind of
  non-activity. As one of the clients sighs
  coming through the door. You feel yourself as
  human being again while coming in here. The
  workers say that they are available, if the
  clients want to, and that the clients know this.

12
What is harm reduction?

• Pursuit of evidence based practises
• Harm reduction as thin principle -gt situational
  interpretations and changing hierarchies of
  different drug related harms
• From pure health-counselling to health and
  social counselling
• Different contexts and orientations (face to
  face, education nights and sessions, the street
  and homes)

13
Extract 2, fielddiary, august 2005

• Sirkka tells me about the principle of their
  work. It is to keep things as they are, in status
  quo, so people wouldnt get any worse. I
  remember, what Anja told me in her interview. It
  is absurd to think that people would find their
  way to the treatment, if their life is a big
  mess. If I had lost a near one and at the same
  was in their situation, I dont think I would be
  able to abstain from drug use. It is when things
  are quite well, when people have the energy to
  make arrangements in their lives.

14
Extract 3, interview, march, 2006,Maija-62, peer
worker

• I tried to help people, in anyway I can, but not
  to give amphetamine to them for debt. They can
  sleep here, I can make food for them and, you
  know, wash their clothes evenfill out some
  formsyou know, rather than give them a bag and
  send them awayAnd many have said to meit is so
  cosy and quiet in here.

15
Extract 4, fielddiary, october 2003, Jussi-55,
peer worker

• Jussi is bit critical about direction the
  education is going, with different practical
  advice, how to diminish drug related harms in the
  everyday life. There isnt enough discussion
  about the real problems that drug users
  havemental health, homelessnessHe tells with a
  hint of irony, how phony it is to send people
  away with an advice to change their socks to
  clean ones, when they are desparate and in agony.

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Needle exchange and drug treatment system
alternative or support?

• Critique needle exchange services as liberal and
  drug oriented
• Rather, a supportive role a step towards other
  services as well as a back up
• Building trust as important miniature model of
  society
• Specialized field of expertise street wisdom
  knowledge of the everyday lifes of drug users and
  first hand experience of latest trends taking
  place on the field
• Workers as advocants, interpretations and
  diplomats

17
Extract 4, Matti-51, interview, may, 2005

• I was getting tired of shooting and running
  after it and, you know, started to think of
  having some other options for itBut it felt so
  difficult and tiring, you know, to get to the
  treatment and all, with all the regulations and
  demands. It felt like they dont want you
  therewithout these services, I wouldnt be where
  I am knowI would be six feet under.

18
Extract 5, interview, Tipi-83, may 2006

• How do you think people see these services?
• I dont know, I see them as importantit is easy
  to come here and somebody is always ready to talk
  with you and the workers,they know my name. This
  like my living roomif I go to the social
  services, they look at me, you know, whether Im
  going to jump at their throats..you know, the way
  the look at you

19
Conflicts in the system

• Marginalized positionmarginalized respect
• Treatment as something noble and harm reduction
  as something suspicious
• Your clients vs. our clients, lack of
  solidarity between different actors
• Needle exchange services as scapegoats

20
Extract 6, fielddiary, april 2006

• An angry young man enters the service. There has
  been some trouble with his social worker,
  something about the place in the nearby
  dormitory. The man is VERY angry. Now I
  understand why people hit somebody with the ax on
  the subway, he mumbles. Aino, one of the worker
  asks if she can help. After brief negotiation and
  some phone calls she manages to get new
  appointment for the man After half an hour or so
  the man comes back. Nothing has changed and there
  is still no place for him for the night. Aino
  regrets and wonders what went wrong, even if she
  had made the call and everything. When I said,
  that you arranged this meeting, she said that
  workers in here dont have any power over
  anything the man says laughing ironically.

21
Extract 6, interview, female executive, april
2006

• And if you think about the situation where I
  was..I called to this public official (about the
  funding) and she said thatwe are talking about a
  group of clients in here, whose own influence to
  their current life situation is great I think
  You can get the picture, when I say that people
  in high places have a very negative attitude
  towards this work.

22
Consequences of needle exchange 1. Drug users

• New identities and possibilities
• Care yourself and others
• Security as part of life
• Improvement of the quality of life

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Consequences2. Treatment system

• Needle exchange as an addition, not an
  alternative
• Revelation of blindspots in the system (e.g.
  problems in treatment entrance as well as in the
  ways treatment is carried out and what happens
  after care problems of inequality and life-long
  exclusion problems of mental health treatment
  problems in prisons)
• Important window to marginalized drug users (e.g.
  not one subcultures, but many importance of
  individual life history and overall capacities in
  the treatment and management of addictive
  behaviour)
• Possibility of social critique and redefining the
  addiction concept (back to social)

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Discussion possibilities of harm reduction

• Possibility of new stories (see Fitzgerald 2002)
• Drug users as active citizens, not just passive
  objects of interventions
• The diminishment of the stigma and possibilities
  of new identities
• Outpatient care as serious alternative to
  treatment in institutions

25
Obstacles of harm reduction

• Stereotypic images
• Competition between different actors and services
• Problem of bad publicity and lack of public and
  official support gt Catch 22 situation
• Problems with financing