Harm reduction is under attack in San Francisco. Mayor Daniel Lurie (D), the Board of Supervisors and even the San Francisco Department of Public Health have declared that tolerance, compassion and harm reduction-based services for people who use drugs have gone too far.
“We have to take care of people in a different manner,” Lurie said, “and it’s not by allowing them to continue to use and die on our streets.” A “different manner” actually means a crackdown. It means street distribution of foil, pipes and plastic straws is no longer allowed, with programs that offered harm reduction supplies from tables on sidewalks ordered to move indoors. It means more destruction of tent encampments, more police harassment and ticketing of people sitting or laying on sidewalks.
The controversial Reset Center, described as a “law enforcement-led crisis stabilization center,” was opened in May. Police bring people they deem to be under the influence of drugs to be held in the locked facility for 24 hours.
This is the climate in which the Harm Reduction Therapy Center (HRTC) now operates. Founded in 2000, HRTC offers free counseling, operates a drop-in center and distributes safer-use kits to people who use drugs.
“We are not moving that person in a direction that somebody else thinks is important.”
They also have a van that parks in several neighborhoods and operates as a mobile pop-up, drop-in center. Their harm reduction therapy comes with hospitality: comfortable seating, canopies, coffee, snacks or a hot meal. It’s truly “meeting people where they’re at.”
HRTC’s Maurice Byrd and Anna Berg are all too familiar with the current backlash against harm reduction in San Francisco. Byrd is a licensed marriage and family therapist, and the center’s clinical training director. Berg is a licensed clinical social worker, and the clinical program director. Both have decades of experience working with people around drug use and mental health diagnoses.
Filter asked Byrd and Berg for their thoughts about the changes under Mayor Lurie, the human impacts of the rejection of evidence-based harm reduction services, and how this reflects an era of rising authoritarianism. Our interview has been edited for length and clarity.
Helen Redmond: What is your response to the critics of harm reduction who say it enables people to use drugs and keep on using?
Maurice Byrd: Harm reduction enables people to stay alive. It enables a person to be healthy and as safe as possible. Ultimately, we’re not invested in people continuing their drug use if that’s what they choose and we’re not invested in people pursuing abstinence unless that’s what they choose. And I think that is what is difficult for people to really understand and that’s what is controversial. As harm reductionists, we don’t come in with a goal in mind for someone. So we’re truly in a collaboration with our clients to create those goals.
Anna Berg: When you say you’re enabling, it brings up an assumption that there’s something that somebody wants the person to do—that we are not forcing them to do. And so we are not moving that person in a direction that somebody else thinks is important.
MB: I have a quick story. We were working at a shelter-in-place site, and a staff person who is now under scrutiny from the law called me into the office and asked, “Are you going to give our clients drugs?” That was her question!
I said, “Wouldn’t that be illegal for me to give your clients drugs?” And I said no, I would not. Then she asked, “Well, you’re going to make sure they have drugs?” And I was like, “I’m not in the business of drug dealing. I’m a therapist.”
AB: We also want to help people think about what their options are. And sometimes folks get into spaces where it’s hard to know what the options are, they forget, get in a pattern, or in a survival place where all somebody can think about is what’s the next few moments. It’s part of our job as harm reduction therapists to help people explore and consider their options. And that’s the thing we enable people to do.
HR: In a recent article by German Lopez in the New York Times, he wrote, “People struggling with addiction often need an outside push—from a family member, a friend or ultimately the government—to seek help.” Lopez argued the majority of people he’s interviewed said they needed threats and pressure to stop using drugs. What is your response?
MB: We’ll just call that for what it is: cherry-picking. That’s a cherry-picking story. Do you know the number one way that people recover? It’s on their own without any intervention, something we call “aging out.” It’s not harm reduction, it’s not AA. It’s actually just spontaneous.
I spent a fair amount of time in forensics working with people in custody in the San Francisco County Jail and San Quentin State Prison. I don’t want to completely say that coercive treatment, even though I disagree with it greatly, hasn’t been a starting point for some people. There could be an intervention that helps people jump off and do something different. It could be a starting point for some, but overall, that’s absolutely not how people recover.
AB: Change is hard, even if it’s something you really, really want to do, even if it’s something people in your life really want you to do. You have to have a sense of possibility, hope, and empowerment to take on change. Coercion and carceral treatment takes all the empowerment out and just forces and traumatizes folks. It undermines the whole change process. It causes harm and then what a lot of folks are doing to cope with harm is maybe the thing that brought them in contact with law enforcement in the first place. There’s something very misguided about what people think substance use treatment should look like. It can be authoritarian and paternalistic.
HR: Critics of harm reduction are saying the focus is too much on drug-user rights and not enough on the impacts of drug use on families and communities.
MB: We hear this mostly from politicians. This is a political question, because politicians could do something about it. You can make more drop-in centers. You could, God forbid, make safe consumption sites so people are not using outside on the streets. Oh my God, why not house people so that they have their own safe consumption sites, which is for most people their home?
Other countries have decided that they don’t want any neighborhood to be open drug zones, like Switzerland. So they invest in those neighborhoods in ways that reduce it. They decriminalize or legalize substances.
The politicians want to lay it at our feet because we treat people who use drugs with dignity and respect in a way that other people do not. We do it in a public way. I think that’s hard whenever people see that we’re treating people with respect, and they’re like, This person doesn’t deserve respect.
This is not a problem of harm reduction and this is not a treatment question. There is a scapegoat that needs to be created.
AB: You could actually make quality, engaging, compassionate treatment that people would be excited to go to because the whole person is attended to, not just one aspect of their life.
Harm reductionists are looking at harm and impact and we’re looking at it on multiple levels. If there is harm to communities, families or to individuals, that needs to be part of the conversation. And that absolutely is part of the conversation in San Francisco. We’re in the business of trying to be part of the solution and invite folks into a thoughtful conversation of what their needs are.
“They’re looking for people who fit a particular demographic. The other troubling part about the Reset Center: You’re not being arrested or detained—in my opinion, that’s being kidnapped.”
HR: Talk about the newly opened Reset Center in San Francisco.
MB: It’s authoritarian. Who do you pick up off the streets? Unconscious bias exists, racism, and most of them are going to look like Black and Brown people. They are the ones who are going to get snatched off the street. Most of them are going to look like “people who use drugs”and people who are experiencing homelessness.
If they’re looking to take people off the streets who are inebriated, go to the Marina District. Go to the Marina every night. Go to the Castro every night. Go to these neighborhoods. [Instead] they’re looking for people who fit a particular demographic. There is the other troubling part about the Reset Center: You’re not being arrested or detained—in my opinion, that’s being kidnapped—and you can’t leave until you are cleared by someone.
AB: We don’t want people to be outside using substances and struggling. Let’s invite people inside. Let’s do that. It will cost less. It will get less pushback. If we do that, we won’t have court cases—because we’re bordering on some legality issues with the Reset Center.
HR: What does the drug treatment landscape look like in San Francisco?
MB: Since the ‘80s, we don’t have community mental health centers in the sense that we used to have them. Why don’t we take some of the money out of waging the drug war and invest that in actual treatment?
This idea of a “War on Drugs” is obnoxious because you can’t get into a war with drugs, it has to be people. We’re in the middle of prohibition right now that’s killing people because we’ve decided to let drug dealers figure out the quality of the fentanyl that is being used, not the government. So this is a prohibition issue, it’s a race and class issue, too.
There’s a big push with the Reset Center, they want people to go into treatment. Where are they going to go? There isn’t enough treatment available.
We need treatment on demand, low-threshold—the lowest threshold possible. Wouldn’t that be phenomenal, if somebody walked up to a place and said, “I’m ready for residential treatment” and they walked right through the door?
AB: How do we do it that any door is the right door for somebody to come into treatment? As a service provider, I’ve experienced the barriers to treatment. There’s a phone number to call to get somebody into residential treatment or for intensive case management services. Every time I call, I’m asked, does that person have all their medications with them, any suicidal thoughts in the last 90 days, do they have insurance, an ID? Even when I have that person, there’s a wait.
“We need housing that is nice, not shitty, that doesn’t take all your money and you have rats for roommates.”
HR: Mayor Lurie and the San Francisco Board of Supervisors have rejected harm reduction and said it’s been tried and it’s failed. Where is that coming from?
AB: We’ve never fully implemented the principles of harm reduction into our drug treatment system, in our care system or in our health care system. We can’t say that it hasn’t worked, because we actually have not fully implemented or adequately funded programs. And it’s the same for Housing First. People say that they have a Housing First model and folks adopted some of the spirit of it, but a true Housing First model is really beefed up on services, has a really high touch point, and offers an array of supported services.
We need housing that is nice, not shitty, that doesn’t take all your money and you have rats for roommates.
The facts don’t matter. Politics and emotion dictate public health policy now. We’re in an era of rising authoritarianism, and only folks with money matter. We’re in this space where certain people’s opinions are more important than others. It’s leading us into a big mess.
MB: We never fully realized the dream of harm reduction. Since 2000 every contract for social services [in San Francisco] had to have a harm reduction philosophy. I call it a philosophy, because it’s not actual policy. It’s what we call “diet harm reduction,” or harm reduction-light—which means that it was written in your contract, more than anything else.
The problem with authoritarianism is that you don’t listen to people. You don’t listen to people like Anna or myself or Jeannie Little or Patt Denning, who have been doing harm reduction based work in San Francisco with people experiencing homelessness and using substances and mental health issues for 30 years.
We’re really right on the verge in San Francisco of violating human rights. We’re like, right there. We’re taking freedom away from people.
Photographs by Helen Redmond