Harm Minimisation: A Strategy of Sorts
by Peta Dale B.B.Sc. (Hons.); Dip. Psychotherapy

Origins of Harm Minimisation concept.

Its use as a treatment approach for drug users.

Limitations in school settings.

Alternative prevention strategies.

The growth of concern over the spread of HIV/AIDS in the mid-80s served to lend political acceptability to policy development that was based on a Harm Minimisation approach. In the 90s, the original purpose was broadened to include other health issues and now targets a range of students within various programs. The education community has readily adopted Harm Minimisation, with schools being encouraged to implement the concept as a health promoting strategy. Educators and students may benefit from an awareness of the risks and limitations of the Harm Minimisation approach.
 

The term Harm Minimisation is used widely and is associated with drug related strategies. More recently, Governments in Australia have used the term in relation to drug issues and the policy adopted. However, ambiguity surrounding the meaning of the term confuses the attractive aim and value of minimising harm with the actual strategy or policy which has its own limits, basic assumptions and target group. Clarity in defining the nature of the approach enables greater understanding in terms of its appropriateness for any particular individual or group.
 

Harm Minimisation began as a movement by public health specialists attempting to deal with the threat posed by AIDS to illicit drug users. Approaches such as needle exchange programs were developed with this aim in mind. One main premise behind the argument for the strategy is that some drug users cannot be expected to cease their drug use at the present time (Single, 1995) and that drug use is seen to be normal, rational and beneficial to the user. The task is to minimise the risk, or occurrence, of harm in the situation (Wright & Saunders, 1995). This involves manipulating the drug taking environment, the how, when and where of the drug taking rather than the drug use itself.
 

One way to clarify the term and distinguish between conflicting approaches would be to differentiate between “the minimisation of harm” and “a harm minimisation approach”. If we are to be clear about the origins of the approach, the target group, the aims and the limitations, then there is a need to define harm minimisation as fundamentally a treatment approach. Most drug policies or programs, even abstinence-oriented programs, attempt to minimise drug-related harm. When confused with the strategy under the same name, any distinction between strategies becomes lost under the general aim of reducing harm.

In essence, Harm Minimisation is a strategy to ameliorate the adverse consequences of drug use while, in the short-term, drug use continues. Within this definition, abstinence-oriented programs and the use of criminal law to deter drug use would not be considered Harm minimisation measures (Single, 1995).

The initial conceptualisation is a long way from the current usage of the term by the National Drug Strategy. Harm Minimisation is defined as a policy “involving a range of approaches to prevent and reduce drug-related harm, including prevention, early intervention, specialist treatment, supply control, safer drug use and abstinence” (ADF, 1998). Here it would seem that there is a multitude of approaches, each with its own target group; be it the whole population as in prevention, at risk groups for early intervention or drug taking groups as in safer drug use.

The reference point determines and guides attempts to develop goals. When the reference is the drug itself rather than the person, we see the aims to control the drug through; Supply, Demand and Harm. These can be seen in the core strategies of Drug Education - Supply control, Demand reduction and Harm reduction (ADF, 1998). This may have led to the terminology of “war against drugs” as often seen in news reports and the concern that this war may become a war against the drug users themselves. Another reference point may be the individual, the person who has desires, thoughts and behaviour in relation to drugs. From this reference point our aims might be placed in terms of preventing abuse, eliminating use or minimising harm. Perhaps a useful way to categorize treatment approaches is in terms of the target group and the appropriate treatment for that group.

A diagram below illustrates examples of different approaches to drug education in light of the stages in the process of drug-taking behaviour and emphasizes the differences between Harm Minimisation and other approaches.
 

Several other approaches can be seen as falling under the headings of either preventative or abstinence approaches. These are information based, personal and social development based and social skill training based. Within the education environment these approaches are not usually presented in isolation. However, the distinction between these approaches can be made in terms of the relevance and appropriateness of the approach for the individual and his or her stage in the drug taking process.
 

A World Health Organisation Expert Committee (WHO, 1993) advises that a concern often expressed about Harm Minimisation strategies is their potential for communicating a message condoning drug use and suggests that these concerns can be alleviated by targeting the message to those already involved in hazardous drug use. Despite this, the Committee continues to advise that the public health sector has always been in favour of reducing immediate drug related harm, even if this involves some risk or can be seen as condoning drug use. This can be seen as understandable as a response in light of the fears of the spread of HIV in the community. However, it seems questionable whether or not the risk of condoning drug use is necessary or warranted in the school situation.
 

The historical context from which the Harm Minimisation strategy developed, the limitations and the target group, all have some bearing on the usefulness and appropriateness of this strategy in the educational setting.

A problem with Harm Minimisation as a health promoting strategy for the classroom is that it targets all teenagers. It sets up the expectation that all teenagers are using drugs, all are sexually active, etc., which is not the reality for the majority.

Geoff Munro (Australian Drug Foundation, 1998) reports that over one third of all students aged between 12 and 17 years have tried cannabis. This leaves the majority of two thirds who have not tried cannabis. Only a minority of drug users is said to graduate to regular or problematic use and these are the adolescents most likely to be already troubled.

The original intention of Harm Minimisation reflects a compassionate and realistic approach of “being tolerant of the frailty of people who may be harming themselves but who aren’t capable of changing their behaviour” (Bevan, 1993). This approach may not be appropriate for teenagers who particularly need clear messages conveyed to them nor for those most in need of help who may be least likely in the long term to benefit from such a permissive message.

The harm minimisation drug strategy is only one approach, an approach that is appropriate to those already taking drugs and who cannot be expected to cease their present drug use. Presenting an approach that indicates or suggests tolerance to harmful drug taking gives that message to all students. To take it a step further, there may be a possibility that a false sense of security is given inadvertently through the harm minimisation approach, for example, educating on how to give and gain assistance in the case of an overdose.

The aim of the Harm Minimisation approach is not to minimise the use but the harm - the message conveyed does not discourage the habit. One of the fundamental weaknesses of this strategy is that it is divorced from the underlying values that may prompt behaviour change. Teenagers need guidance, they need to be told that its harmful to misuse drugs, what the consequences of sexual activity are, etc. Simply giving them information about how to reduce drug-related risks is not enough.

Harm Minimisation deals with the consequences of the act and the final outcome. It does not deal with underlying reasons for drug misuse and doesn’t effectively communicate a non-use message. If health education is to work at this level, the bridge between intention, knowledge and action must not be cut. The message must be sufficient to be able to influence the intention to avoid smoking, drinking or drug misuse and to behave in a sexually responsible manner.

More and more students are in fact looking to teachers for guidance. In the national “Rural Mural” research project undertaken by the National Centre in HIV Social Research - Program in Youth/General Population, students were shown to be looking to teachers to provide them with more information on the sociocultural aspects of sex. Boys nominated a need for more discussion around values about sex, whilst girls were keen to obtain more information on developing skills to resist the pressure to have sex (Hillier, Warr & Haste, 1996). If guidance and support is what is needed in such situations then Harm Minimisation may not be the ideal starting point. By presenting a “safe sex” message, a Harm Minimisation strategy may just miss the mark. A preventive message that addresses the needs of the adolescent may be more appropriate and beneficial in the long term.
 

The Victorian Government’s response to the Report of the Premier’s Drug Advisory Council, June 1996, can be viewed in the Implementary Strategy titled “Turning the Tide”. A range of approaches is desirable, including the original conception of the Harm Minimisation approach. Within schools, goals address both drug education curriculum and drug-related student welfare. When this is translated to the educational setting, the “best fit” in the approach to the issue of drug misuse becomes most important. One position may be to address the drug taking process at the initial stage of motivation and thought, the aim being to prevent the development of a drug related problem. Another stage to address may be that of the act itself with the aim to eliminate use. Primary prevention is no doubt the best starting point, particularly for the younger students.

The long-term goals of enhancing protective factors and making a positive contribution to the wellbeing of young people reflect a primary prevention approach that targets the population. Schools are in a position to be able to implement preventative strategies. The Resilience Project and The Student Transition and Resilience Training (START) Project are working at the prevention stage and are designed to enhance resilience, self-esteem and life-coping skills as well as the quality of social relationships and environments. These Turning the Tide projects, plus community-based initiatives such as Open Doors’ Resilient Kids Program, promote a message of maximising potential in contrast to the message given through the inherent limits of a harm minimisation approach.

More information about Open Doors Counselling and Educational Services, including the Resilient Kids CD-ROM, is on this website.

Australian Drug Foundation (1998) The Framework of Drug Education. drugEDnet, http://www.adf.org.au/drugednet/es.html

Bevan, G. (1993) In a Spiritual Vacuum: The Religious Dilemma of Harm Minimisation. Connexions 13:6.

Hawks, D. & Lenton, S. (1995) Harm Reduction in Australia: has it worked? A review. Drug and Alcohol Review 14:3, pp. 291-304.

Hillier L., Warr D., & Haste B. (1996) The Rural Mural: Sexuality and Diversity in Rural Youth. A Report to the Community. Faculty of Health Sciences, Latrobe University.

Mellor, N. (1991) Harm minimisation - a public education issue, a case of live and let live. In: Autumn School of Studies on Alcohol and Drugs (1991: Melbourne, Vic.): Proceedings, p.131-141.

Monro, G. (1998) School-based drug education: realistic aims or certain failure. Australian Drug Foundation.

Resilient Kids Program. Open Doors Counselling and Educational Services:
http://www.opendoors.com.au

Single, E. (1995) Defining harm reduction. Drug and Alcohol Review 14, pp. 287-290

Victorian Government response to the Report of the Premier’s Drug Advisory Council, Turning the Tide, June 1996.

Whelan, G. (1991) Harm Minimisation In: Autumn School of Studies on Alcohol and Drugs (1991: Melbourne, Vic.): Proceedings, p.127-129.

Wodak, A. & Saunders, B. (1995) Harm minimisation drug education: A cautionary tale. In: Bartu, Anne (ed.) 11th Mandurah addiction research symposium: proceedings 1995, p.22-28.

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Updated May 2005