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Improvements...no less than heroic : Harm reduction and learning in Vancouver’s Downtown Eastside Alkenbrack, Betsy 2007

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  Improvements….. no less than HeroicHarm Reduction and Learning in Vancouver’s Downtown Eastside Betsy Alkenbrack    Capilano College/WISH Drop-in Society/Lifeskills CentreImprovements….No Less than Heroic 2                 Improvements…… no less than Heroic Harm Reduction and Learning in Vancouver’s Downtown Eastside written by Betsy Alkenbrack, Capilano College  with input from Diana Twiss, Capilano College Additional commentary by Sarah Evans, InSite, Vancouver Coastal Health Editorial and Research support by Marina Niks and Suzanne Smythe, RIPAL-BC Capilano College/WISH Drop-in Society/Lifeskills Centre Funded by the National Literacy Secretariat December 2007 Cover Art: “My Healing Journey” by Ruby Ann Pete. March 6, 2007 Improvements….No Less than Heroic 3                                  Table of Contents INTRODUCTION ..................................................................................................6  Research Questions .............................................................................................6  Background.........................................................................................................7  A Research in Practice Approach .....................................................................8  Report Overview .................................................................................................9  A Note about language .......................................................................................10  Glossary of Terms...............................................................................................10  PART ONE: REVIEW OF LITERATURE ON HARM REDUCTION AND  LESSONS FOR LITERACY WORK...................................................................12  What is Harm Reduction (HR)?...........................................................................13  Harm Reduction with Injection Drug Users (IDUs).........................................17  Addiction .............................................................................................................17  Quality of Service................................................................................................20  What does progress look like?............................................................................21  The role of the Harm Reduction Worker .............................................................22  Peer Programs....................................................................................................25  “All My Relations”: holistic approaches inspired by First Nations traditions ........26  Lessons for Literacy work ...............................................................................26  Harm Reduction with Sex Trade Workers.......................................................28  Violence ..............................................................................................................29  Health .................................................................................................................30  Poverty................................................................................................................30  Lessons for Literacy Work ..................................................................................32  Literacy Programs, Practices and Practitioners ............................................32  Literacy with Homeless people ...........................................................................33  Literacy with Women in Conflict with the Law .....................................................34  Literacy with Survivors of Violence .....................................................................35  Final Lessons from the Literature ...................................................................36  What is Harm Reduction? ...................................................................................36  How does Harm Reduction link to learning? .......................................................37  How can community colleges like Capilano and our community partners support  harm reduction in our learning activities?............................................................37  Table 1: Principles and Practices in Harm Reduction, Literacy and Learning  ............................................................................................................................39  Improvements….No Less than Heroic 4                                Table 2: Comparison of Progress Criteria in Harm Reduction and Literacy  ............................................................................................................................40  PART TWO: RESEARCH ON HARM REDUCTION AND LEARNING IN  VANCOUVER’S DOWNTOWN EASTSIDE .......................................................41  Research Methods ............................................................................................41  Data Collection....................................................................................................41  Data Analysis ......................................................................................................45  Research Findings............................................................................................45  1. What is Harm Reduction and how does it affect Downtown Eastside  residents who engage in high-risk behaviours?............................................45  Defining Harm Reduction....................................................................................45  Crisis Management .............................................................................................46  Foundation Building ............................................................................................47  Engaging.............................................................................................................47  2. How does Harm Reduction link to learning?..............................................50  3. How can Capilano College and our partner learning centres support  harm reduction..................................................................................................52  Harm Reduction Principles .................................................................................52  Bread and Roses ................................................................................................53  Building connections ...........................................................................................55  A safe space for learning ....................................................................................56  Asking the Right Questions.................................................................................57  Working with Peers .............................................................................................57  PART THREE: CONCLUSION AND RECOMMENDATIONS............................60  Recommendations............................................................................................61  FOR FURTHER READING/SURFING................................................................63  REFERENCES ...................................................................................................64  ATTACHMENTS.................................................................................................67  Attachment A: Focus group outline .....................................................................68  Attachment B: List of Harm Reduction Strategies mentioned by research  Attachment C: Suggestions from Research Participants re: the kinds of  participants .........................................................................................................69  workshops and training experiences needed in the Downtown Eastside............71  Attachment D: A page from the UpWords newsletter.........................................72  Improvements….No Less than Heroic 5                                                                          1 INTRODUCTION  I have seen a lot of addicts go through many ups and downs, but who really recognizes the true value of improvements that these people make themselves? ……. Taking everything into consideration – upbringing, background, lifestyle and environment, the sheer will to gain control and make improvements is no less than heroic for a ‘junkie’ or addict. Looking closely, we believe that we all have addiction issues and these deserve to be humbly evaluated! (Johnny Knox, inUpWords1 1(1), September 2005) This observation by a street-involved drug user highlights a key issue that adult educators must consider if they want to be successful in Johnny’s neighbourhood: that any change in a program participant’s lifestyle must happen on their own terms, at their speed, following a path that works for them.   That is central to the philosophy of Harm Reduction, which Robertson and Poole (1999) describe as "a philosophic and practical approach to numerous interconnected humanrealities (drug use, sexuality, relationship violence, safety, etc.)". Harm Reduction recognizes that: x  risk is a natural, universal part of all our lives;  x  drug users experience both benefits as well as risks/harms from using substances, and  x  people change at their own pace, based on things such as readiness, motivation, safety, information, skills and beliefs.  We will describe Harm Reduction in more detail in the Literature Review Capilano College works with community groups in Vancouver’s Downtown Eastside to operate learning centres for adults with “high-risk” lifestyles (including drug use, working in the sex trade, living with violent partners and being street-involved). We, the instructors who manage and teach in those learning centres, wanted to learn more about Harm Reduction and how we could use it to improve teaching and learning.  Research Questions In this report, we describe the literature we read and the research we conducted to investigate the following questions:  1. What is Harm Reduction and how does it affect Downtown Eastside residents who engage in high-risk behaviours?  2. How does Harm Reduction link to learning? UpWords is produced by the Stimulant Discussion Group at the Lifeskills Centre in Vancouver Improvements….No Less than Heroic 6            3. How can Capilano College and our partner learning centres support harm reduction in our learning activities? We also argue that:  x  Working in literacy and learning centres in places like the Downtown Eastside with people at risk may benefit from a Harm Reduction approach to teaching and learning. x  People engage in many learning opportunities to learn about harm reduction (safe sex, needle use, living with violent partners, etc).  x  Learning can enhance Harm Reduction and vice versa.  Background This project was conducted over a two-year period by Capilano College instructors as part of our work at two centres in Vancouver’s Downtown Eastside: the LifeSkills Centre and WISH (Women’s information Safe Haven).  The Downtown Eastside LifeSkills Centre The LifeSkills Centre is a resource centre that provides a barrier-free environment for drug users to access basic services such as laundry and showers, and to enter low threshold programs and classes. There are over 1600 registered card carrying members, and an average of 760 visits daily. Programs include community kitchens, a library, a women’s wellness group, classes delivered by neighbourhood organizations (such as Women against Violence against Women), Art Therapy classes, a book club and the UpWords newsletter group. UpWords is produced by and for stimulant users. The Lifeskills Centre works in partnership with InSite – Vancouver’s (and North America’s) only publicly-funded Safe Injection Site. WISH (Women’s Information Safe Haven) WISH is a drop-in centre offered exclusively to women in the survival sex trade. About 100 women come to the drop-in each night for dinner, a shower, access to free clothing, supplies and make-up, a consultation with the street nurse or just to relax infront of the TV before they go back to the streets.  Three nights a week, about 10-20 women make their way to the WISH Learning Centre, which has been operating since 1999 in partnership with Capilano College. Here they can read, do crafts, work on the computer, get individualized help with courses such as high-school upgrading, participate in workshops, or write for the quarterly newsletter. Capilano College has been operating the learning centre at WISH for eight years, and when the opportunity came for us to work with the Lifeskills Centre, it seemed like complimentary work. Both organizations seek to serve people who are “hard to serve” - marginalized, victimized, criminalized, stigmatized and not accessing mainstream services. Many women who use WISH at night go the Lifeskills Centre during the day, to participate in the Women’s Wellness group, art workshops, grief and loss groups, Improvements….No Less than Heroic 7                meetings of Sex Workers Action Group or the various community kitchens. Also, both organizations have a common approach to working with drug users and sex trade workers: they do not require them to be “in recovery,” “exiting the sex trade,” or even not using drugs – everyone is welcome in whatever state. So because of that, both organizations are excellent places to investigate the links between Harm Reduction and Learning. Recognizing these facts sheds light on the pragmatism of harm reduction.  Our research builds on previous research done by Capilano College and the WISH Drop-In Centre Society, called Literacy for Women on the Street (Alderson & Twiss, 2003). This report describes a journey three educators and a group of learners took to discover: "How can literacy activities empower and stabilize the lives of women in the sex trade?" In the process, they revealed and debunked three myths about sex trade workers: x  Myth 1: Women who work in the sex trade are just objects, they have no minds. x  Myth 2: Women who work in the sex trade and/or use drugs are not “ready” to learn x  Myth 3: Street involved women are not interested in building their minds or getting pleasure from thinking, reading, discussion or analysis. (p. 1) The research Alderson and Twiss did at WISH lead to a new understanding of how to work with women living “in conditions of extreme poverty and violence” (p. 25) -- women for whom low self-esteem and the need to meet basic needs often hinders their ability to participate in learning activities. The women who participated in the researchshowed how important it is to create safe learning spaces that are non-threatening, non-judgemental and address women’s needs in realistic ways.  In the present research, we build on Literacy for Women on the Street by exploring theliterature and practice of Harm Reduction to find out how it can influence and improveour work. A Research in Practice Approach This is a Research-in-Practice (RiP) project. RiP is conducted by practitioners abouttheir own teaching situation. In their study of the state of and potential for Adult Literacy Research in Practice in Canada, Jenny Horsman and Helen Woodrow (2007) say: “Unlike other research processes RiP captures, from practitioner experience and knowledge, detailed evidence about what works and what does not in ways that can most effectively improve literacy practice” (p. 6). In an earlier study, Horsman and Mary Norton (1999) say, “the value of research in practice must be recognized for its potential to improve literacy practice, supporting the field in developing and changingand exploring new directions and possibilities” (p. 20).  This approach to doing research seems particularly fitting for the topic of Harm Reduction. Both RiP and Harm Reduction challenge traditional ways of working and ways of knowing - and whose knowledge matters. Both are, fundamentally, about respecting people on the ground: valuing their expertise and validating knowledge that Improvements….No Less than Heroic 8                                                               is learned through experience and practice. Harm Reduction challenges the “abstinence only” approach to working with participants – both in health and education – while RiP challenges notions that all the expertise is housed in universities. As Susan Lytle (1997: 2) observes, "When teachers systematically and intentionally inquire into their practice, often in concert with colleagues, they value and draw on their own ways of seeing and knowing”. Report Overview In Part One of the report, we describe the literature on Harm Reduction work with injection drug users and sex trade workers, also briefly touching on psychological and clinical literature on the roots of addiction and how long-term drug use or trauma affects certain neurological functions. We also discuss reports on literacy work with homeless people, women in conflict with the law and survivors of violence. This focus on the literature is in keeping with a view that Research in Practice is not just about practitioners doing research, but also reading research and applying it to practice(Horsman & Norton, 1999; Horsman & Woodrow, 2007).  We use the literature to check for congruence between literacy and Harm Reduction practice and to see how we can improve our educational work using Harm Reduction principles. The literature helped us to “see things in a different way” (Horsman & Woodrow, 2007: 7). Part Two of the report describes the research we conducted about our practice with street-involved people at WISH and the Lifeskills Centre.  We conclude the report with Part Three, a summary of the research and concluding comments about: x  activities and approaches to learning that include, engage, respect and work with this “hard-to-serve” population (including learners who are active in their addiction)  x  how paying attention to Harm Reduction can enhance our work in learning centres Capilano College instructors conducted this research in partnership with the WISH Drop-In Society and the Downtown Eastside Lifeskills Centre. Betsy Alkenbrack collected the data and did the literature review, then compiled the report in consultation with DianaTwiss and Sarah Evans. Between us, we have worked at WISH for a total of five years and Betsy worked at the Downtown Eastside Lifeskills Centre during the year that the research was conducted. Sarah is a manager at InSite, the Safe Injection Site. We haveall worked with marginalized adult learners for many years and our department has an eleven-year history of working in partnership with Downtown Eastside organizations. We are also active Researchers-in-Practice: Diana has been a researcher and contributor to four research projects (Alderson & Twiss, 2003; Battell, 2001; Battell, Gesser, Rose, Sawyer, & Twiss, 2004; Hoddinott, 1998) and Betsy is active with RiPAL-BC2, a group2 Research in Practice in Adult Literacy, British Columbia Improvements….No Less than Heroic 9              that supports and promotes RiP in BC. Marina Niks and Suzanne Smythe from RIPAL-BCprovided editorial and research support for this report.  Conducting this research has been very helpful to us as practitioners, and we hope other adult literacy practitioners who are curious about Harm Reduction will find it useful too. It may also be useful to other front-line workers who use a Harm Reduction approach in health, workplace or community sectors.  A Note about language We have used “we” – representing the team as a whole –to introduce you to this research report, and will use it again at the end of the report. However, the literature review and the description of the research will be written in the first person singular (“I”) because the experiences described and the reflections on the literature and the research process are written from Betsy’s perspective. In some cases, we have added comments from Sarah, and this is noted.   Glossary of TermsAddict: “a person who is devoted to or obsessed by an activity, habit, or substance” (dictionary.com). The original meaning of addiction was  “voluntary slavery” and it did not become associated with drugs until 100 years ago (notes from presentation by Bruce Alexander, July 2004). There are many different kinds of addictions (money, sex, television, coffee) and there would still be addiction if there were no drugs. In this report the word “addicts” usually refers to people who are addicted to drugs and/or alcohol.  Cocaine: “a crystalline tropane alkaloid that is obtained from the leaves of the coca plant…..It is both a stimulant of the central nervous system and an appetite suppressant. …. It gives a feeling to what has been described as a euphoric sense of happiness and increased energy.” (Wikipedia) Crystal Meth is methamphetamine hydrochloride, the street form of the drug methamphetamine that comes in clear, chunky crystals and is heated and smoked (Facts on Crystal Meth, CBC Fifth Estate, http://www.cbc.ca/fifth/darkcrystal/facts.html ) Drug Users: I use the term “drug users” to describe people who use drugs when it is not important to distinguish how they take the drugs (for example, by injection or smoking). Some of the literature refers specifically to injection drug users, or IDU’s. One of the focus groups, the UpWords Editorial team, is composed of people who usestimulant drugs. They feel it is important to make this distinction and explain why on page 47. Opiates: A medication or illegal drug that is either derived from the opium poppy, or that mimics the effect of an opiate (a synthetic opiate). Opiate drugs are narcotic Improvements….No Less than Heroic 10             sedatives that depress activity of the central nervous system, reduce pain, and induce sleep. Side effects may include over sedation, nausea, and constipation. (Treatment Solutions 411 ttp://www.treatmentsolutionsnetwork.com/dictionary.aspx). Examples: heroin, morphine or codeineStimulants are drugs that temporarily increase alertness and awareness. They usually have increased side-effects with increased effectiveness, and the more powerful variants are therefore often prescription medicines or illegal drugs. Examples: cocaineand methamphetines (Crystal Meth) (Wikipedia).  Street-involved: People who are street-involved often support themselves on the street (for example, by working in the sex trade or buying, selling and bartering licit and illicit goods). They may also live on the street, socialize there and engage in street culture, temptations and risks. Survival Sex work: Anyone who can’t exercise their right to refuse performing sexualacts for food, shelter, drugs, money or other survival necessities” (Living In Community, p. 36). Improvements….No Less than Heroic 11                      PART ONE: REVIEW OF LITERATURE ON HARM REDUCTION AND LESSONS FOR LITERACY WORK It is typical for practitioner-researchers to have a love-hate relationship with  literature. For example, in the RiP report Dancing in the Dark (Niks, Allen, Davies, McRae, & Nonesuch, 2003) the researchers argued that they had a different relationship with literature than those trained to do academic research, and that the literature review would not improve the report or the research in a way that would benefit those we were hoping to reach. It would not helpestablish a conversation with either adults with little formal education or adult literacy practitioners (p. 8) Practitioners often prefer to engage in discussions, workshops and face-to-face exchanges with other practitioners, and consider their fellow-practitioners to be more trustworthy sources of expertise than literature that comes out of universities (Horsman& Woodrow, 2007; St. Clair & Chen, 2003). As a practitioner, I also seek out every opportunity to exchange ideas with others in my field and have enormous respect for their experience and wisdom. But for this research project, I was drawn to the literature, and indeed found it easy to apply to my work in adult literacy.  This could be because most of the literature reviewed here is practice-oriented and written by Harm Reduction practitioners, whom I feel a great affinity with. Like most Adult Literacy practitioners I know, they tend to be committed to social justice and see it as central to their work. In a study of HIV/AIDS prevention workers in Vancouver, John Egan (2003) interviewed practitioners from a variety of different professions, including nurses, physicians, social service workers, outreach workers, counsellors, therapists, educators, program coordinators or supervisors, staff in treatment programsfor addiction and drop-in centre staff. He found that “69% (cited) a personal commitment to social justice as one of their reasons for working with IDUs (Injection Drug Users)” (page 8). This commitment shines through in the literature on Harm Reduction and may have been the hook that made me want to read more.  In this section, I describe and discuss the literature on the following topics: x What is Harm Reduction?  x Harm Reduction with Injection Drug Users  o Addiction o Quality of Service o What does Progress look like? o The role of the Harm Reduction Worker o Peer Programs o Holistic approaches to harm reduction x Harm Reduction with Sex Trade Workers Improvements….No Less than Heroic 12                   o  Violence o  Health o  Poverty x  Literacy Programs with Homeless people, Women in Conflict with the Law, and Survivors of Violence Each section is concluded with a description of the “lessons for literacy work” and the entire section concludes with a summary of the lessons organized by the three Research questions:  1. What is Harm Reduction and how does it affect Downtown Eastside residents who engage in high-risk behaviours?  2. How does Harm Reduction link to learning? 3. How can Capilano College and our partner learning centres support harm reduction in our learning activities? In some parts of this literature review, I have included comments by Sarah Evans. She is reacting to the literature on Harm Reduction with Drug Users, bringing her specialized experience as manager of Vancouver’s Safe Injection Site (InSite) into the review. Each of her comments is prefaced with “Sarah’s response”. What is Harm Reduction (HR)? Harm Reduction is a pragmatic approach that focuses on decreasing the negative consequences of drug use for communities and individuals. It recognizes that abstinence-based approaches are limited in dealing with a street-entrenched open drug scene and that the protection of communities and individuals is the primary goal of programs to tackle substance misuse. (MacPherson, 2001: 4) This definition of Harm Reduction comes from a A Framework for Action: A Four Pillar Approach to Drug Problems in Vancouver. The four pillars included in the framework are prevention, treatment, enforcement and harm reduction. The report argues that each pillar should interact with each other and as well as other municipal initiatives “that aim to improve the overall well being of the community”, such as business development, community safety, health and housing initiatives. This policy document is linked to an agreement signed in1999 by the City of Vancouver, the Province of British Columbia and the Government of Canada known as the Vancouver Agreement.  The agreement commits these government partners to work together, and withcommunities and business in Vancouver, on a coordinated strategy to promote and support sustainable economic, social and communitydevelopment.(The Vancouver Agreement, 2000)The initial focus of the agreement is Vancouver’s Downtown Eastside. Improvements….No Less than Heroic 13            I have started this section with a definition from the Four Pillars Report because I think it helps to set the context for an exploration of how we can apply Harm Reduction principles to programs in Vancouver. Other literature on Harm Reduction provides lists of principles, such as one developed by the US-based Harm Reduction Coalition (Harm Reduction Coalition) -- see Table 1, page 31) or descriptions of philosophy. The onehere seems to be particularly congruent with adult literacy work, especially for those who use a learner-centred approach. Marlatt (1998) describes HR as Viewing individuals as responsible for their own choices and as both agents and recipients of environmental influence is central to the harm reduction paradigm. Individuals must be engaged "where they are" and moved from there in small manageable steps to increasing levels of improved self-care, health, and well-being. (Marlatt, 1998: ix) In her critique of the Four Pillars (discussed in more detail below) Erin Graham given the following explanation for HR:  Harm reduction is, broadly speaking, a set of strategies and treatment methods used in the treatment of drug and alcohol addiction (though the use of the term has ‘leaked’ into many areas of social policy). These strategies are meant to meet the addict where s/he is, and to offer alternatives to methods or sites of drug use, as well as treatment options that gradually move the person toward health care services and drug treatment programs. (Graham, 2007: 12)Similarly, learner-centred approaches to adult literacy try  to meet the learner where she/he is, value the development of self-esteem and advocate personal or individual empowerment (Norton, 2001: 13). In practice, learners are supported to set their own learning goals and work towards them at their own pace.  Another way to understand HR is by assessing competing philosophies or approaches. For example Erickson, Riley, Cheung and O’Hare (1997) describe three competing views on how to work with drug users: prohibitionist (drug use is “morally wrong”), legalization (de-criminalization and killing the black market – a sensible approach, but too radical for some) and the medical model (drug users are medically deviant, bad or sick). The authors argue that Harm Reduction challenges all these approaches because it is value-neutral, avoids over-simplification and assumes the user is active rather than passive. Sarah’s response: Our perspective needs to be humanistic and holistic.  Users are learners, not just students; human beings, not just clients; agents, not victims or service-recipients.  Like all of us, users are people with hopes, dreams and potential, not just case studies. Another comparative description comes from Bruce Alexander (2001), a respected Simon Fraser University-based expert on addictions. In a 2005 seminar for residents of Vancouver’s Downtown Eastside, he described how three overlapping periods in Improvements….No Less than Heroic 14            Vancouver’s history in which drug use was approached differently: From WW1 to 1985, a “Policing” approach was used, featuring horrendous police brutality, long jail terms and heavy police activity. From 1960-1995 the focus was on psychological treatment for drug addiction, with a lot of money going into treatment programs.  And from 1990 to the present, a Harm Reduction approach has predominated, featuring less punishment, and more acceptance, but also less money available for treatment. Alexander argues that Harm Reduction is the best and most humane approach, but it will not eliminate or reduce the drug addiction problem.  This literature focuses on drug use, but parallels can be made with other areas of risk such as violence, street entrenchment and sex trade work. For example, a recent history of the sex trade in Vancouver (Francis, 2007) describes how the reigns were tightened and loosened over the years by legislation and social attitudes. The variations in the law were often in response to political and commercial pressure, rather than concern for the welfare of the sex-trade workers.  Another way to understand Harm Reduction is to examine its many practical forms, ranging from establishing needle exchanges, supplying bleach to sterilize needles and other supplies used to take drugs; promoting safer sex, providing referrals to primary health, psychotherapy and alternative treatments, to providing access to housing, advising on drug use management including safer drug use, the substitution of less harmful drugs, and advocating for policy change (Marlatt, 1998). Erin Graham (2007) reports that HR initiatives In the Downtown Eastside have included:  a needle exchange service (initiated by the Downtown Eastside Youth Activity Society (DEYAS) in1989) and methadone maintenance programs , drug court (2001) , a safe injection site (September, 2003—currently operated by the Portland Hotel Society, or PHS), and recently, a one year trial run of the NAOMI project (North American Opiate Medication Initiative, Spring, 2005)operated by the Vancouver Coastal Health Authority), which prescribes heroin to addicted people who meet certain criteria (Graham, 2007: 12). A criticism of Harm Reduction approaches is that they condone or even support drug use, thus standing in the way of users who genuinely want to get off drugs, off thestreets, or out of a violent relationship. Erin Graham (2007) draws on her experience as a mental health worker in the Downtown Eastside to write a thesis that is critical of Harm Reduction, and particularly the Four Pillars policy. She writes:  watching the implementation of the four pillars drug policy in Vancouver has been rather like watching Michael Jackson’s face—beginning beautiful, with some kind of hope, some kind of will to make changes and slowly taking the twisted and uneven shape it has today, with Harm Reduction and Law Enforcement squaring off in a ring of fire that is the DTES, with no real winners but the human services industry (Graham, 2007: 168)She argues that Harm Reduction as it is currently practiced in the Downtown Improvements….No Less than Heroic 15                                                             Eastside may reduce the spread of disease, visibility of drug-users and social disorder, but does not reduce harm. Her arguments are both practical and political. Practically, she points out that while resources have gone into Harm Reduction services, there is still a shortage of detox and residential treatment services, particularly for women and women with children.  She is also critical of projects like InSite and the NAOMI project 3 because they focus on medical services only, “(t)hough several studies and reports highlighted poverty, social isolation and attendant political disengagement as ‘social determinants of health’” This criticism seems to ignore the partnerships throughout the Downtown Eastside that allow groups with different expertise to work together, providing a continuum of care. For example, people who use InSite go to other programs for social support, and staff at the Carnegie Learning Centre recently provided training for workers at the new detox centre at InSite so that they could provide better support for people who want to work on their education while they are intreatment. On a political level, Graham argues that current Harm Reduction projects do not address social issues and the targets of HR policies (drug users and residents of the Downtown Eastside) may become even more marginalized as a result of those policies (p. 8). She attributes this to the high amount of surveillance, including the sign-in procedures. However, my experience is that sign-in sheets are voluntary and participants are free to not sign in or to use false names. Another very serious criticism is that HR policies serve to maintain levels of addiction that prevent participation in the mainstream. :  I argue that specific policies and practices related to the Four Pillars serve to maintain people at a level of addiction that may keep them from resorting to criminal behaviour, or from contracting HIV, or dying from overdose. However, these same policies and practices may also ensure they will be unable to either participate in mainstream life or to organize with each other in order to change the conditions within which they live. (Graham, 2007:10) Harm Reduction defenders differ. In their “Backgrounder on Harm Reduction” Robertson and Poole (1999: 1) say: “Harm Reduction…. embraces recovery and abstinence as healthy options, goals, and aspirations to be explored by an substance user." Marlatt stipulates that abstinence must be freely chosen, with the user setting the time frame. For many users, abstinence simply isn’t an option  – in fact, only 5-10% of the drug-using population is prepared to consider abstinence-based programs (Riley& O'Hare, 1999: 21, my emphasis). As literature in other sections shows, Harm Reduction and support for abstinence can work in partnership. Practitioners can provide support, referrals and information to participants who want to get off drugs or out of a 3 The North American Opiate Medication Initiative, a clinical trial that is testing whether heroin-assisted therapy benefits people suffering from chronic heroin addiction who have not benefited from other treatments. http://www.naomistudy.ca/pdfs/naomi_faq.pdf. Improvements….No Less than Heroic 16               violent relationship, but also discuss how to use drugs more safely or make a safety plan for their current living situation. Sarah’s response: Independent, peer-reviewed scientific research shows that the opening of InSite was associated independently with a sharp increase in detoxification service use, increased rates of long-term addiction treatment initiation and reduced injecting at the Safe Injection Site.  (View the researchat www.communityinsite.ca). Where possible, harm reduction programs like InSite do build bridges for addicts to access detox and recovery; however, these programs also aim simply to keep people alive long enough that they might have time to make healthier choices for themselves.  Dead people do not detox.No one is saying that it is okay, in our economically affluent society, to havepeople living such lives.  None of us want to keep people in this place, or enable these kinds of addictions.  Nevertheless, this oppression and social exclusion is a reality – and one that we as a society have not been able to address or solve. Harm reduction approaches allow us to take health care to the community and “meet people where they are at.”With this overview in mind, the next section of this literature review looks more closely at how Harm Reduction has been applied to work with Injection Drug Users, followed by Sex Trade Workers and Survivors of Violence.  Harm Reduction with Injection Drug Users (IDUs) Addiction Dr Gabor Maté is currently writing a book about addiction (In the Realm of Hungry Ghosts: Close Encounters with Addiction, forthcoming Spring 2008), based on his long-standing experience as a physician to residents in the Downtown Eastside, including many patients with addictions. In a presentation to the staff of the Carnegie Centre, Maté provided a definition of addiction, which helped me to better understand Harm Reduction work: Addiction involves behaviour that is repetitious, has negative consequences, and that you continue in spite of dire consequences in your life. It is not the object that characterizes addiction, but the relationship to the object. According to Bruce Alexander, the original meaning of addiction was “voluntary slavery” and it was only 100 years ago that it became associated with drugs.  As Johnny Knox says in the introduction to this report (page 4) we all have addiction issues, and both Alexander and Maté support this statement, citing examples of addiction to gambling, money, power and consumerism.  In his 2005 seminar, Alexander observed that “there would still be an addiction problem if there were no drugs.”  Alexander argues that one important factor contributing to addiction is dislocation, and failure to achieve psychosocial integration – something he claims is endemic in our free-Improvements….No Less than Heroic 17             market society, in which workers are expected to be “independent economic actors”, moving where the jobs are irrespective of commitments to family, friends, community, cultural traditions, values, religion, ethnic group or nation (Alexander, 2001: 4). He also says that dislocation is particularly rife in Vancouver, “the most addicted city in Canada” (p. 8) and that Harm Reduction as a social policy is not adequate, although it is the best we have right now. What we really need is a society where people have other choices, where life is good enough that people don’t enslave themselves to drugs:Although the four pillars are compassionate and useful in combination, society cannot “prevent,” “treat,” or “harm reduce” its way out of addiction any more than it can “police” its way out of it. ….The key to controlling addiction is maintaining a society in which psychosocial integration is attainable by the great majority of people. People need to belong within their society, not just trade in its markets. (Alexander, 2001: 20) This seems to be in line with Graham’s critique (see previous section) but it is offered in a way that supports the spirit of Harm Reduction.  Alexander and others designed an interesting research project to investigate ppsychological and situational variables in the appearance of addiction (Adult, Infant and Animal Addiction). Previous studies had shown that laboratory animals, under the right conditions, will persistently ingest or self-administer opiates and other drugs. They choose morphine in preference to water, and in large enough quantities to produce withdrawal symptoms.  These findings bolstered the notion that drugs (particularly narcotics) are intrinsically and dangerously irresistible (Alexander, 2001: 78). However, Alexander et al. argued these studies failed to take into account the setting in which the animals were housed: often strapped in to self-administration machines, constrained and isolated. In contrast, the team built a deluxe “rat park,” which mimicked the natural environment and gave the rats room to play and socialize. This phase of the experiment showed that rats in Rat Park were less likely than caged rats to be lured into drinking morphine.   The researchers then habituated both groups of rats to morphine and put them on acycle of no fluid days, morphine-only days, and morphine & water choice days.  In all phases, the caged rats consumed more morphine than the others, sometimes up to 8xas much. In contrast, the Rat Park rats actually decreased their consumption slightly over the same period! The researchers theorized that learning about the drug's withdrawal effects reduced their willingness to ingest it. They concluded that, just as with human beings, an animal's response to being offered and withdrawn from narcotics is influenced by situational factors.  When given reasonable alternatives, these animals chose ordinary pleasures and activities over both the initial temptation of the drug, and the eventual motivation to avoid withdrawal discomfort (p. 84). And when there are no reasonable alternatives, drugs can have a positive, adaptivevalue (for example, Murray & Ferguson, 2003; Tatarsky, 1998).  Improvements….No Less than Heroic 18                Sarah’s response: Dr. Gabor Mate posits that crystal meth and other stimulants are used by many people attempting to self-medicate for otherwise untreated and often undiagnosed Attention Deficit Disorder.   Many people use drugs in order to distance themselves from their own negative thoughts and feelings.  After a few days in detox, painful memories start tosurface which are simply too awful to face, and this is often a precipitating factor in a relapse.  While it no doubt brings with it a considerable set of drawbacks and risks, drug use is what helps some people to get through the day. Our research participants also mentioned this, and Lisa Olm, writing in UpWordsnewsletter, says it most eloquently:  A lot of Crystal Meth addicts use it because it is cheap and easy to get, but most of all for pain relief. Pain, including the effects of emotional and physical abuse, as the result of growing up in a dysfunctional home or family. Many addicts were not given a choice, as they were subjected to it at an early age and need it to function normally.Gabor Maté also makes a strong case for the role of connection and attachment in addiction. In a presentation to Carnegie Community Centre staff (December 2006) he explained that drug addicts typically have circuitry in their brains that have not developed properly. The attachment circuitry (the drive to attach to others and feel loved) is fuelled by the chemical endorphins.  Heroin resembles endorphins and attaches in the same place in the brain. It is a powerful attachment chemical, and makes you feel loved and accepted. The “Incentive Circuitry” is stimulated by dopamine, which makes us feel alive, excited, enthusiastic and able to get on with our life. Cocaine and Crystal Meth stimulate 300-1200 % more dopamine than in natural conditions, and Cocaine shuts down dopamine receptors in the brain, especially with ongoing drug use.Maté argues that “the war on drugs isn’t working” and that an abstinence approach does not work because of the high stress level most addicts experience. He also makes a very sobering observation about his patients: that all the drug users he has worked with – especially Injection Drug Users – have experienced some profound form of childhood abuse, with “no exception”. They have experienced sexual abuse (especially women), abandonment, serial abandonment (moving from one foster home to another)and have been responsible for protecting younger siblings from abuse. And to recognize the moral complexity of these situations, many victims have grown up to be abusers. (information taken from notes on presentation, Carnegie Community Centre, December 2006) Sarah’s response: I’d like to point out the moral complexity of these situations: Many victims grow up to be addicts or to be abusers in turn. As a society, we Improvements….No Less than Heroic 19                                                           feel sorry for children who are neglected or mistreated - but if they turn out to be addicts as adults, we blame and punish them. Along the same lines as Alexander’s statement that “people need to belong”, Maté says addicts can only heal in an enriched environment, with food, housing, love and support so that the circuitry can develop. This process takes much longer than the three- to six week provincially funded recovery programs currently available. In long-term residential treatment, Stage 1 usually involves a 90-day program with no outside work or study. Stage 2 provides housing for graduates of the residential program while they reintegrate into the community. Sarah’s response: Another Perspective I listened with interest to a piece about Dr. Jean-Charles Crombez that aired on CBC Radio's Ideas a few years ago4.  Although his point of reference is mostly about death and dying, I found his comments very pertinent to people who are addicted to illicit narcotics. Drawing on Crombez’ ideas, it is possible to argue that many traditional addictions treatment programs take the approach of attempting to "cure" an addicted individual of their addiction.  This tack focuses solely on the "problem" of addiction, and ignores all the other traits, dreams, fears that make up each human being, addict or not.  Further, by proposing that adherence to a particular program of care, these programs indicate that the powers of healing are outside the individual, thus further disempowering individuals who are likely already suffering from social dislocation and disassociation from self. On the other hand, some recovery programs break this mold.  As far as I can see, such programs are successful so precisely because they do not propose to be a cure for addiction; in fact, they do not focus on addiction to any particular extent.  Instead, they focus on the participants -- individually, in their families, and collectively -- and they seek to assist addicted people to heal as humans, not as addicts. In this sense, addicts are reminded that they are on the same journey towards self-understanding and greater wisdom as any of us.  In my opinion, recovery programs should not exist to detox drug addicts, but to nurture human beings. The difference between “curing” and “healing” reminds me of the difference in literacy between “teaching” and “learning.”  It goes back to ideas of agency and about what kind of knowledge (and whose knowledge) matters. Quality of Service With this understanding of some of the roots of addiction, we can go on to think about what kind of services are most useful and can promote health, safety and learning among drug users, their friends and families. In the article, “Working with lives and not just veins” Cavalieri (1998) asks questions about the quality of service to drug users. 4 Healing Part 1:Jean-Charles Crombez, CBC Ideas http://www.cbc.ca/ideas/features/healing/Improvements….No Less than Heroic 20                    These questions refer to needle exchanges, but they could easily be asked about other services: ƒ How available are the needle exchanges?  How friendly and welcoming? ƒ What is the attitude of the management of these exchanges, and how does that impact on service? ƒ How are Injection Drug Users viewed by the exchange personnel? What is their attitude about drug use?  ƒ  Do the exchange workers take the time (or have the time) to develop  empowering and supportive relationships with the people who use the  exchanges?ƒ  Are the workers themselves supported and empowered?  Sarah’s response: I might add:  ƒ Are the staff themselves supported and empowered to learn about themselves?   ƒ Are the staff encouraged and supported in self-reflection?  ƒ Is there a sense of acceptance and tolerance, belonging and community in the  exchanges?  ƒ Is there a budget and plan for staff development?  ƒ Is there a mechanism for clients / participants to provide feedback on the  program? ƒ Is it possible for clients / participants to get paid or volunteer jobs in the program? ƒ Are the programs or services set up around staff needs or client / participant needs? What does progress look like? According to Harm Reduction philosophy, it makes sense that any discussion of “progress” in a drug user’s life should be on a drug-user’s terms. An article by Ruefli and Rogers (2004) describes some criteria drug users apply to measure their own progress, and challenges traditional ways of measuring based on quantity and frequency of drug use. They suggest that more appropriate measures are based on the extent to which drug users organize their lives around drug use, how much drug use is integratedinto their lives and the extent to which it negatively impacts other aspects of their lives. The drug users in their study identified ten important life areas: making money; getting something good to eat; being housed/homeless; relating to families; getting needed programs/benefits/services; handling health problems; handling negative emotions; handling legal problems; improving oneself; and handling drug-use problems.  Sarah’s response: Note that for these users, the problem of drug-use is in last place on their list of program priorities, after important priorities like eating, making money, finding shelter, etc.  This seems to indicate that until those basic, underlying needs are addressed, it would be premature to address drug use. Despite this seemingly common-sense notion, addressing drug use often the first or exclusive focus of treatment or recovery programs. Improvements….No Less than Heroic 21           In their study with Harm Reduction workers in six Toronto agencies, Janet Murray and Mary Ferguson (2003) identify three stages to building stability in users’ lives (p. 45). The first stage is crisis management, characterised by depleting assets, living in crisis and cycling in and out of chaotic drug use. They point out that, although drug use can cause problems, it does not necessarily always lead to crisis. In come cases, “people can lead engaged, working lives while using (drugs)” (p. 46). As noted above, most of us use some kind of drug: caffeine, sugar, alcohol, etc. The next stage is foundation building, characterised by coping, accessing basic needs and building stability. Here, animportant step is to find housing (p. 49). In the third stage, engaging, users begin to build assets, improve their quality of life, become more self-directed, and connect to the community and economy. At this stage, many people begin engaging in the community by attending community programs and volunteering.   Sarah’s response: I think engaging and relationship-building is the first step.  Without this, you cannot start to work on the rest. The role of the Harm Reduction WorkerMurray and Ferguson found that, as the user moved along these three stages, the role of the Harm Reduction worker shifted gradually “from a responsive, action-oriented role towards the role of providing ongoing problem-solving, counselling and encouragement." (Murray & Ferguson, 2003: 53). There is also a shift from strictly one-to-one support to peer group support.  At all stages, the focus is on behaviours connected to the drug use, not the drug use itself (something Maté also stresses). Although the user is becoming more self-directed as they shift from survival mode to long-term thinking, an anchor relationship with a harm reduction worker is still very important: “just knowing that a friendly, accepting, non-judgmental person is always available can give users the confidence to take risks and make dramatic changes" (p. 52). Andrew Tatarsky (1998) speaking from a psychotherapists’ perspective, describes a way of working that is similar to the way many literacy  practitioners approach their work: the therapist would be actively committed to the person who seeks help, and should be experienced as an ally rather than a threat. Not all Harm Reduction work conforms to these guidelines. In Advocate, Mentor orMaster? John Egan draws on his work with Vancouver HIV prevention agencies, to examine the power relations between harm reduction workers and their clients (Egan, 2003). He identifies three roles that prevention workers take:  the Advocate is client-centred and gives priority to the client's agenda – but this is limited because they don’t give guidance. The Mentor challenges the client's agenda and tends to intervene more than the advocate, encouraging them to think for themselves and “find concrete ways to improve their lives." (p. 6). Egan notes that  "…instilling in her clients a sense of agency is more important than simply fulfilling their wishes." (p. 6). The third role prevention workers can take is that of a Master, trying to control their IDU clients. Improvements….No Less than Heroic 22                 Literacy workers, like Harm Reduction-oriented prevention workers, would do well to examine the role they take in their clients’ lives. While Egan notes that all three approaches represent a worker’s efforts to improve their client’s lives, he also asks:  (I)s it appropriate for these workers to direct their IDU clients, towards a 'better' life? Or is holding any notion of what would constitute a better life, itself inappropriate? If clients are disempowered, even ignorant, and workers dare not challenge them -- based on following a wholly client-centred, advocacy-based agenda -- isn't IDU oppression being perpetuated by an unwillingness to intervene? (Egan, 2003: 8) Sarah’s response: Accepting, from a pragmatic perspective, that addiction is a reality does not mean that we throw up our hands and throw our clients to the wolves. Egan recommends that professional development initiatives related to harm reduction include analyses of power relationships between the “harm reduction worker” and “client”. Anne Docherty, a community educator and researcher in Hazelton, BC, echoesthis advice. She argues that it is important for practitioners to "take time to articulate their values, principles and approach to their work and to recognize that they have an agenda when entering a relationship with learners." (Docherty, 2006: 5).  Sarah’s response: This is a crucial part of staff development, and often under-funded. The Women’s Options for Risk Reduction through Knowledge of Self (WORKS) is a harmreduction intervention described in two studies looking at harm reduction programs with women Injection Drug Users (L. M. Brown & Gilligan, 1992; N. L. Brown, Luna, Ramirez, Vail, & Williams, 2005). This intervention enacts a philosophy that sees Harm Reduction as an empowerment tool for patients -- providing HIV prevention workshops,counselling and testing to female injection drug users (IDUs) or their partners. The goals were to teach women to recognize their own HIV risk, use HIV-prevention strategies and access local health services, but not to stop using drugs. The paper by Brown and Gilligan looks more specifically at how community-based organizations (CBOs) can collaborate to provide effective interventions and services for clients at riskof HIV, as well as the barriers to collaboration, and how these can be overcome. Researchers identified the following four issues as important in collaborative interventions. They would all be important considerations in a literacy context:    x trusting relationships between staff and program participants; x clear, easy to follow information on how to help participants gain access to services;  x support services such as child care and  x adequate time and resources to meet participants’ needs.  These researchers, along with several others (Garcia, 1999; Marlatt, 1998; Murray & Ferguson, 2003; Tatarsky, 1998), describe the journey of a drug-user’s life as non-linear Improvements….No Less than Heroic 23                                                               and incremental. Murray and Ferguson note that users cycle back and forth, in and out, between stages. In the San Francisco Treatment Guidelines, B. Garcia says  Relapse or periods of return to use should not be equated with or conceptualized as "failures of treatment." As substance abuse treatment providers have always understood, the "road to recovery" is paved with many twists and turns (and) total abstinence is difficult to achieve….. Harm reduction approaches can also decrease the emotional and physical damage associated with these episodes. (Garcia, 1999) In “Working the floor: the role of the counsellor at the Sydney Medically Supervised Injecting Centre” 5this approach is described as follows: (T)o contextualise the role of the MSIC as a ‘gateway’ for injecting drug users into drug treatment programs, it needs to be appreciated that the MSIC occupies the chaotic endpoint of the harm reduction continuum,serving a notoriously challenging and marginalised client population, considered ‘too hard’ and intransigent for most health services for drug users. The expectation that this population will readily transcend both the complexity of their daily existence and the impoverishment of their histories needs to challenged. Change of this magnitude is typically a slow and fickle struggle. This is not an argument for defeatism but rather a case for strategic pragmatism forged through experience.  In the meantime MSIC continues to provide a service where the possibility for long-term change is fostered and its short-term absence is accepted (p. 6). Sarah’s response: For most people, actively looking for a way to deal with their addiction is a process that takes 10 years.  Addiction is a chronic, relapsing condition. Let’s face it: for any of us, change of any magnitude is a slow and fickle process. Harm Reduction workers therefore need to be patient and non-judgemental.  Brown and Gilligan argue that we should be equally patient with organizations trying to  work together:  Just as women in the groups were educated to make changes in high–risk behaviours in a slow, incremental manner, so too, the multiple agencies involved in this collaboration learned that working together in an atmosphere of changing staff, different organizational cultures, limited funding resources and high demands, and ever changing time lines, also require a slow and steady approach where communication and a willingness to change are crucial factors. (L. M.Brown & Gilligan, 1992: 332) 5 http://www.sydneymsic.com/Improvements….No Less than Heroic 24                  And finally, Erin Graham reminds us that, in this high-burnout profession, a shared political analysis is vital: I came to believe that working on behalf of, or with “disenfranchised” populations, has the potential to be burn-out work unless a at least two conditions are met: 1): A strong theoretical political analysis fuels the work, and other workers share this analysis, and 2): there is a commitment to provide support, empathy, mutual aid and political solidarity rather than ‘service’. (Graham, 2007: 15)Peer ProgramsTwo of the programs in Murray and Ferguson’s report established peer support projects for drug users. This seems to be a promising practice in the Downtown Eastside and elsewhere (for example Mason, 2006). In the Downtown Eastside, Life Is Not Enough Society organizes about 200 peer shifts per week in the local harm reduction service sector, and the LifeSkills Centre is almost entirely peer-run.  So it is worth paying attention to when it comes up in the literature. In the Toronto programs described by Murray and Ferguson (2003), the goals of the peer programs were: x  to enhance organizations' ability to promote awareness of harm reduction  practice among users  x  to support the process of educating the wider community about harm reduction x  to provide stabilized users and ex-users with an opportunity to use their  knowledge an skills to engage in the community.  x  to offer users a means to make a legal income.  Harm reduction workers observe that, because it is important for the peer programs to go through a process of group development, internal discussion, education, and priority setting before they become effective, the peer groups may take a long time to develop. (Murray & Ferguson, 2003: 70) Sarah’s Response: It is important to be sensitive to the possibility that peerstaff might end up being used as simply a cheap source of non-union labour.  Or, peers might be relegated to menial tasks, given few opportunities to learn,grow or lead on the job. Or, that their perspectives and voices might be marginalized or silenced at staff meetings and in other communications.Yet there is so much to be gained from engaging peer staff members.  I am reminded of some literature on workplace literacy programs that engaged and trained peer tutors.  Program evaluations showed that while the learners did gain from their participation, the peer tutors experienced the greatest growth.  Many tutors became more actively or positively involved in their workplaces, unions or organizations, and in their communities and families.  Some went on to pursue further education for themselves. (Connon Unda & Clifford, 1997: 145-161) Improvements….No Less than Heroic 25               “All My Relations”: holistic approaches inspired by First Nations traditions First Nations’ world views and philosophies such as the medicine wheel, offer a holistic approach to learning that is also useful for thinking about harm reduction work. (for example, Morgan, 1997; Morrish, Horsman, & Hofer, 2002; Norton, 2004; Sochatsky & Stewart, undated; Trumpener, 1997). An example we found in the health promotion field is a First Nations approach to alcohol and drug abuse treatment called The Red Road (Edmunds, 1998). The cornerstone of this is the Lakota term "Mitakuye Oyasin" (All My Relations.) – a phrase that is often used by First Nations participants and their allies in Downtown Eastside projects – which recognizes that we are all related, and drug users continue to have a relationship with addiction, whether in recovery or still actively using. Connecting Harm Reduction to this philosophy means viewing various substances and practices as “relatives” rather than as enemies: alcohol and drugs are relatives, addiction is a relative and Harm Reduction itself is a relative. Edmunds explains that Native teachings promote an understanding and acceptance of two opposite “medicines” – laughter and tears.Edmunds’ advice to Harm Reduction workers is to create an “informative, user-friendly” drug treatment experience and an environment in which they experienced equality, shared problem-solving and a caring atmosphere. Lessons for Literacy work While a harm reduction worker may have a different skill set from an adult literacy practitioner, both types of practitioners share attitudes and approaches. First, we bothneed to have a clear understanding of how addiction works and how it can affect learning. Secondly, we should be familiar with the particular needs and interests of drug users to do our work effectively – for example, by recognizing the adaptive, positive affects drugs may have and working with this, rather than against it. And thirdly, while relationship building has always been a goal in literacy programs (in the context of plummeting self esteem) Alexander and Maté’s arguments make this aspectof our practice even more important.  Sarah’s response: (It is also important to) take and have the time to build relationships; and the support to engage in one’s own learning and development. The questions that Cavalieri (1998) asks about needle exchanges could similarly be asked of Learning Centres: How available, friendly and welcoming are they? How do the instructors view drug users? What is their attitude about drug use? Do the instructors take (or have) the time to develop empowering and supportive relationships with thepeople who come to the learning centre? Are the instructors themselves supported and empowered and learning about themselves -- in relationship with the work and the Improvements….No Less than Heroic 26           learners? Constantly remembering to ask these questions and to check with the learners about their answers would be consistent with a Harm Reduction approach. Cavalieri’s final question (Are the workers themselves supported and empowered?) isimportant to ask in the context of program development, staff support and peer programs. In a similar vein, Maté makes the case for self-care among practitioners: “On days when you are tense and haven’t looked after yourself, you will never do the right thing for clients/students.” (Notes from presentation to Carnegie Staff, December, 2006) Sarah’s response: I think it is bigger than this.  This kind of work will trigger people to anger or empathy, but it is important to note that our responses are always about our own issues, our own traumas or pains or whatever.  A supportive work environment is needed to help workers through this so they can also grow and “heal” and not project their issues onto learners and also not become victimized by vicarious traumatization.  This is the piece that is about caring for the caregiver – and about us all being learners. Cavalieri also argues that needle exchanges need to work with the whole person – their communities and families and hopes and dreams – and not just their veins or their problems. We are all learners and we can all experience healing and growth.  Both literacy and harm reduction work involves relationships, events and stories that can trigger powerful emotional responses in practitioners (empathy, grief, fear, anger, blame, love).  It is important for the workplace culture to encourage and support workers in their own personal development.  Often, this starts with noticing our responses to various situations, stories or people, and with recognizing that our responses reflect our own issues.  Supporting staff to reflect, learn and grow through the challenges of this work helps prevent burn-out and vicarious traumatization and helps maintain and nurture caring relationships with consistent, appropriate boundaries. As literacy workers, we are well aware that progress can happen slowly with small steps, but the harm reduction literature reviewed above reminds us to also see it as cyclical and not necessarily linear. For example, Murray and Ferguson describe how users can move from states of “living in crisis” and depleted assets to “building stability” to “building assets”; they note that there is usually a movement both forward and backwards. So a literacy practitioner working with users or other learners who are at risk needs to be prepared (both personally and professionally) for this movement as it relates to learning. In research conducted with Literacy for Women on the Street, Alderson and Twiss found that (W)omen rely on our evenness about their chaotic lives. They thrive on our curiosity about their roller coaster successes and failures, particularly with addictions, but they do not need one more judgement. When we continue to see women as champions of their lives and active learners in all situations, it breathes optimism into their self-concept. (Alderson & Twiss, 2003: 52) Improvements….No Less than Heroic 27                 Another lesson is that harm reduction work can be both clinical (promoting and providing safer sex and condoms, needle exchanges, bridging to treatment programs, etc.) and non-clinical (helping users to access housing, etc.). As literacy practitioners, we might find ourselves involved in support work that is not strictly about literacy – and we should not avoid it, because it is central to relationship building and to learning. It is also linked to the “systems literacy” that helps learners to learn. Murray and Ferguson found that it is also central to effective Harm Reduction work.  For example, when a woman comes to a literacy class having just lost her home or been beaten up by her partner, we cannot ignore that reality and just go on with the lesson.  The literature that describes the skills and attitudes required by harm reduction workers resonates with the skills that are necessary for literacy work. Some of these are: x cultural competence x a non-judgemental attitude x ability to build trust and develop one-to-one relationships (a key issue) x being consistent and caring  x ability to set clear boundaries x ability to help program participants set goals and solve problems.  On a program level, it is crucial to have clear, easy to follow policies and procedures – especially, but not only, if you encourage learners to participate as peers in your organization. The literature talks about educating clients about harm reduction. We are interested inthe role education can play beyond this, just as we are interested in going beyond teaching the GED. So what does that mean? According to Downtown Eastside community worker and instructor, Lucy Alderson who notes that programs such as WISH often “throw out” Maslow’s hierarchy of needs (which says the basic needs need to be in place before you can attend to learning or self-actualization needs). She encouragespeople to seek learning wherever they are:  I see it over and over; people say, “I want to know how to do this. Can you show me this?” or “I’ve decided to get my GED.” You have to be there for that whether it’s at five to five or in the middle of the street, (interview in Battell et al., 2004: 108) Harm Reduction with Sex Trade Workers Sex workers are routinely denied the rights and protections accorded to other workers and, as a result, are forced to live and work in dangerous and demeaning conditions. In many instances, sex workers are not entitled these legal protections because of their source of income. In other cases, they are entitled to these rights… but face practical barriers as a result of pervasive stigmatization and prejudice. (Piche et al., 2006) Improvements….No Less than Heroic 28                                                                           6 This comment comes from Pivot Legal Society’s report on law reform for the sex trade,in which they argue for an expansion of their rights as workers and citizens. The report also touches on the difficult circumstances sex trade workers live in, and like other reports (Alderson & Twiss, 2003; Living in Community Project, 2006), raises the issue of stigmatization and prejudice.The Pivot report also makes a strong case to include sex trade workers in the process of law, policy and social reform. This is beginning to happen: In 2005-06, several consultations with sex trade workers took place in Vancouver, including a meeting with the Mayor about drug maintenance programs and consultations with the Parliamentary Subcommittee on Solicitation Laws, composed of MP’s and Senators from across Canada. Another informative local report is Living in Community, a two-year study of the sex trade industry in Vancouver. The authors describe a wide spectrum of sex trade work.  Our focus in this project is on the group called “survival sex trade workers” defined as: “Anyone who can’t exercise their right to refuse performing sexual acts for food, shelter, drugs, money or other survival necessities” (Living in Community Project, 2006: 36). The report describes the impacts of sex work in a variety of ways, but the most significant to this study are the impacts connected to violence, health and poverty Violence  According to the report Living in Community, 98% of female sex workers in the Downtown Eastside have been victims of violence resulting from bad dates6 (Living in Community Project, 2006: 16). Sex workers are 120 times more likely to be beaten, raped, murdered, kidnapped or mutilated than any other demographic group (p. 37). This is confirmed by earlier studies looking at the lives and histories of sex trade workers in Vancouver (Christensen & Cler-Cunningham, 2001; Currie, Laliberle, Bird, Noelle, & Sprung, 1995; Daum, 1997). In addition, Daum points out that many sex trade workers have been abused as children and in their personal relationships.The Living in Community report points to the ever-present danger of violence at workor on the street, but many women are also at risk at home, where they live with violent partners. We are extremely lucky to have the work of Jenny Horsman (1996; 1998; 2000) to draw on for this important aspect of Harm Reduction. Horsman has worked with literacy learners in contexts similar to ours, and argues that if we want learning to happen, we need to recognize and address the violence and trauma that learners have When a client attacks a sex trade worker it is called a “bad date”. This could result in a rape, physical attack, serious injury or robbery. Sex trade workers in Vancouver are encouraged to report bad dates to atrusted organization and the information will be reported to the police in a way that does not endanger the women. WISH in cooperation with other organizations in the Downtown Eastside publishes a regular “baddate sheet” with the names, descriptions, and when possible pictures of dangerous dates. Improvements….No Less than Heroic 29         experienced at some point in their lives. This has many effects, including learners’ ability to trust, to feel safe and to express themselves. These all, in turn, affect their ability to learn.  There is an interesting parallel between what Horsman says about conditions that enhance learning and what Harm Reduction practitioners say about conditions that support drug users to become healthy. According to Horsman, when we are working with learners who have experienced abuse, we need to accept and work with them as they come to us – not tell them to come back after they have dealt with emotionalproblems resulting from their abuse.  Likewise, literacy practitioners working from a Harm Reduction perspective would not tell drug users to go and get straight and come back when they are ready, or require sex trade workers to leave the trade before they engage in learning. And so Alderson and Twiss (2003) point out that the WISH Learning Centre is “one of the few places where women can be active in their addictions and active in their learning” (p. 26). Also, unlike some educational programs, WISH does not require learners to exit the sex trade before they engage in learning.   Health Sex Trade workers are susceptible to sexually transmitted disease, addiction-related health problems, and are at risk of suffering post-traumatic stress. According to the Living in Community report (and our research participants confirmed this), most sex trade workers use condoms for work, but it is sometimes difficult to negotiate condom use with boyfriends and pimps. (p. 16). Similarly Green and Goldburg (1993) found that the sex trade workers they interviewed in Glasgow did not always use the same rules for safe sex in their personal lives as they did at work, even when their partners were injection drug users (p.13). The issue of sexual health and prevention of sexually transmitted disease is well represented in the Harm Reduction literature (for example, N. L. Brown et al., 2005; Erickson et al., 1997; Marlatt, 1998; Robertson & Poole, 1999; Tatarsky, 1998).  We will not go into that here, except to say that there is a lot of expertise in the community we can draw upon, and we need to continually promote safer sex and respond to participants’ requests for information on this.  PovertyThe Living in Community report writers argue that discussions about sex work usually “exclude factors such as poverty, homelessness and race, which leave individuals with fewer options” (Living in Community Project, 2006: 23). But in our work with sex trade workers, these issues are always on the table: everyone is poor, most are at risk of being homeless and many have to deal with racism. A study of sex trade workers in Victoria who have exited the sex trade found that aboriginal people were over-represented, while members of visible minorities were under-represented (Benoit & Millar, 2001), and the WISH learning centre staff estimate that 65% of the participants are Aboriginal women (personal communication). Improvements….No Less than Heroic 30             Murray and Ferguson’s report (2003 -- see previous section) provides a useful way to look at poverty as it relates to Harm Reduction. They used an Asset-based Framework, which provides a more complex analysis of poverty than simply the absence of money or basic needs. In addition to physical assets (housing, food, services) and financial assets, three other categories are described:  social assets (supports and connections); human assets (which make it possible to engage in economy and society -- physical and mental health, skills, knowledge, education and leadership); and personal assets (self-direction, planning and self-advocacy – the root/launch pad for personal transformation) (Murray and Ferguson, 2003).  Sarah’s response: The social, human and personal assets remind me of Bourdieu’s (Bourdieu, 1984; 1991) notion of cultural, institutional and embodied capital. This analysis goes beyond a discussion of poverty in terms of income orpurchasing power, and highlights some of the interwoven, extensive and intimate ways in which poverty impacts a person’s external and internal lives.Although the focus of Erin Graham’s (2007) thesis was on issues related to drug use, she points out that social policy related to prostitution is parallel (p. 7). She rejects the term “sex trade worker”, claiming the use of this term abandons women as a political class. According to Graham, using this term implies that  “this is a vocation freely chosen from a range of equally accessible and desirable options”. The motivations for this de-politicizing may be noble, to remove the stigma that adheres to women engaging in these activities. But it does not. It legitimates what is essentially male violence against women and children. “Harm reduction” reduces none of the harm to women in these situations; rather it legitimates the actions of the men who commodify and consume women through the system of prostitution. I think Graham is making a very good point on one hand, but missing the point on theother. It is not university-based academics or social service workers who chose to call the women at WISH sex trade workers, but the women themselves. While I fully agree that their lives are full of contradictions, inequality and danger, they deserve to be able to name their own work. Using the word “prostitute” will not improve the situation and it doesn’t seem respectful – and respect is a foundation of both good Harm Reduction and good literacy work. So if this is the reality that we work with, what role can Harm Reduction play? In his review of Harm Reduction and sex work, Rekart (2005) describes several promising projects, including: training in condom-negotiating skills, safety tips for street-based sex workers, self-help organisations, and community-based child protection networks. He also provides a list of principles for doing harm reduction with sex trade workers, which include: x being non-judgemental,  x being respectful of privacy, dignity and views,  Improvements….No Less than Heroic 31               x  including sex workers in the development of programs, capacity-building and leadership development, and  x  “targeting the whole sex work setting, including clients and third parties, rather than only sex workers” (Rekart, 2005) Peer programs can be a great source of learning and support for sex trade workers, just as they are with drug users (see description in previous section). We see peer networks developing naturally among the women at WISH, and three authors describe how they incorporate these into their programs. Rekart (2005) mentions this as a promising practice, and Green and Goldberg (1993) describe a Glasgow-based project in which sex workers were peer teachers. Similarly Olivera (1998) speaks glowingly of the “power of peers”, because they can have a more powerful influence than program workers who have not experienced similar addictions or barriers. Lessons for Literacy WorkThe literature on Harm Reduction work with sex trade workers describes issues related to violence, health and poverty that affect their lives and work on a daily basis. As educators, we need to keep educating ourselves about current developments that affect sex trade workers (including documents such as the Pivot report and Living in Community) and about how violence, drug use and mental health issues intersect with their learning. Where it makes sense to do so, we can include these issues in the learning materials, discussions and writing tasks we bring to the learning centre. We can also, as Alderson and Twiss (2003) say, work in partnership with sex trade workers and support them to take active roles in community development and social change. The next section describes some inspiring literacy and educational programs that have done just that.  Literacy Programs, Practices and Practitioners In their Backgrounder on Harm Reduction, Robertson and Poole (1999) say: ….much of our work is related to helping our clients reduce harm in their lives on issues which are directly and indirectly related to their substance use. Wediscuss: planning to stay as safe as possible with women who are living with violent partners; choices for managing depression … practicing safer sex with partners, etc. It has prompted us to think further about how the policies and practices of our services increase of reduce harm in clients' lives.” (page 1, my emphasis) This comment serves as a challenge to practitioners who may become complacent about the extent to which they are really helping learners or clients to move forward in their lives, in their own way, in their own time. As the writers say, we need to constantly question our work to make sure we are on the right track.  But what practices are most helpful? In this section, I review literature that describesliteracy programs with client groups that seem to be particularly applicable to our Improvements….No Less than Heroic 32        research questions: homeless people, women in conflict with the law and women living with violence. The structure of this section is different from the previous ones: With one exception, all of the documents are curriculum documents or handbooks written for practitioners, and so each one is reviewed separately to highlight the literacy-related issues and practices they describe. At the end of this section, I identify some common philosophies and approaches.  Literacy with Homeless people As you read this, hundreds of social workers, drop-in, and shelter workers and peers are having literacy moments without even knowing it, as they are asked to assist with literacy tasks that are very specific and need to be completed immediately:  Read a letter. Find a number in the phone book.  Help me find where to go.  I need a resume for tomorrow.  Show me how to use the photocopier.  I need to send a fax.  I want to respond to this Hostel Incident Report. (Trumpener, 1997: 2) This excerpt from Gimme Shelter! A Resource for Literacy and Homelessness Work (Trumpener, 1997) is an example of what Betsy Trumpener calls a “Literacy Moment” – and if you work with people who are homeless, or at risk of homelessness, your day is full of such moments. Focussing on survival tasks, the learner is likely not in the position to sit down for an hour of tutoring. So the question for literacy workers who work with the homeless is “What can I teach in 60 seconds?” and “How can I best help this person without doing the task for them?”  Quick and specific as they are, these "moments" of literacy work can still be positive learning experiences for people, and a basis for their return to learning and adult education when their lives are more stable. During literacy moments, we need to be conscious of our practice in order to support the learners' independence and build on their current skills. (Trumpener, 1997: 8) Trumpener describes the “primacy of poverty”, and the inadequacy of focussing on“education as the single solution to economic problems”. For example, a group of homeless women she worked with identified “getting a place to live” as #1 on their priority list, and literacy was not mentioned. This contrasts with the needs of literacy program workers to justify funds by “stressing literacy outcomes and speaking in the language of the marketplace” (p. 24). Trumpener also describes a familiar debate : do people need to be housed before they engage in literacy learning, or can literacy learning “provide the support and tools to establish stability”? (p. 27) Improvements….No Less than Heroic 33                Literacy with Women in Conflict with the LawTwo reports are reviewed in this section: Changing Paths, (Sochatsky & Stewart, undated) a curriculum document, and Motivating women offenders through process-based writing in a literacy learning circle (Stino & Palmer, 1999) a research report. Changing Paths is a program for women in, or at risk of being in conflict with the law.Courses include participatory literacy and life skills, Aboriginal Crafts, a Talking Circle, food preparation, and computer skills. The curriculum document provides a philosophy and rational for the program, reflections on teaching the course and a collection of excellent resources.  The program philosophy is participatory, holistic and humanist. The program promotes an “Integrated Literacy and Lifeskills Approach”, which includes: building a safe learning environment, setting group ground rules, being present, listening, talking about the process of creative writing, inviting women to write and speak and inviting women to connect to themselves through writing.  The authors provide a clear critique of the “deficit model”, which sets out to identifydeficits and develops curriculum to build skills. In contrast the approach promoted in Changing Paths honours the skills women bring to the classroom and focuses on capacity, rather than deficit:  It is an ongoing challenge to look beyond and move deeper into what may initially appear to be a problematic behaviour linked to lack of life skills. Limited interest in reading may be a smoke screen for shame, or not having money to purchase glasses. Lack of classroom participation may speak volumes about old messages that have battered a woman's self worth and self esteem with messages like "Don't talk stupid' or 'Be seen and not heard'. (Sochatsky & Stewart, undated: 12)  They use the image of a butterfly to show how the three different aspects of the program overlay and intersect with each other: Holistic (spiritual, physical, intellectual, emotional), Literacy (reading, writing, listening/speaking, thinking) and Lifeskills (self, family, community, work, education).  The authors also provide some essential advice to facilitators: avoid reminding women of trauma and abuse by reinforcing power relationships they have experienced elsewhere, and do not assume that we, as facilitators, know what they need – always, always ask. The most powerful and healing experiences in the classroom have not come out of a lesson plan (but) as a result of developing a caring and trusting relationship with women. (p. 18) Improvements….No Less than Heroic 34                                                                 In Motivating women offenders through process-based writing in a literacy learning circle, Stino and Palmer (1999) describe a participatory literacy learning circle employing process-based writing activities, offered to ten women who attended a GED7 class in a residential treatment centre for adults and adolescents who had drug offences. A process-based approach to writing pays attention to the steps of writing, drafting, sharing and giving feedback among peers, rather than asking the learner to submit a final, “perfect” product. An interesting aspect of this program is that the women used their own writing to produce a handbook for newcomers to the program to tell them what to expect in a correctional facility. At the end of the program women felt better about themselves because of academic progress, because the book would benefit others and because the teacher cared for them and could guide them. Women who participated in the program also showed some improvement in reading and writing, although improvement in GED test scores were not significant (perhaps because it was too small a group and too short a course to show significant improvement). The authors make a strong case for the benefits of process-based writing (as opposed toproduct-based): it improves skills, helps with coping, improves self-esteem and confidence, helps writers to express thoughts and feelings and to talk, write and read about their own lives. This is confirmed by Sochatsky and Stewart and by Deborah Morgan, who developed the Writing Out Loud program (Morgan, 1997, 2002). Literacy with Survivors of Violence Working with issues of violence asks us to become more aware of the ways we have been wounded and the ways we contribute to the wounding, and take steps to heal and challenge the injustices. (Morrish et al., 2002: 8) Take on the Challenge: A Sourcebook from the Women, Violence, and Adult Education Project provides an analysis of the effects of violence on learning, tools for programs and examples of how ideas were put into practice in a variety of adult education contexts: corrections, ABE, GED, native language literacy, ESOL, welfare-to-work, and homeless shelter programs. In the chapter, “Understanding Violence,” a few points were made that can be applied to our study. First that there are five areas of violence (domestic violence, experiencing or witnessing abuse as a child, violence in public spaces, workplace violence and state violence such as war, police or welfare violence). All of these are applicable to our target group – keeping in mind that the “workplace” is the street. The notion of “state violence” can be linked to the violence of poverty and the systematic harassment many of our learners experience in the welfare system. Morrish, Horsman an Hofer (2002) give examples of how institutions allow and support violence: courts7 General Education and Development, a high-school completion program.Improvements….No Less than Heroic 35             that give a suspended sentence to abusive husbands; welfare limitations that prevent a woman from leaving her abusive partner, welfare rules that force women to take low-paying jobs that do not provide enough for her to pay for transportation, childcare or safe accommodation. Violence is everywhere, taking many different forms that are often intertwined.  When someone experiences one form of violence, she/he becomes more vulnerable to other forms, and "each additional violence has increased impact and deepens the first violation." (p. 10) Educators need to be aware of the impacts of violence on learning, and some of our research participants have mentioned this. Take on the Challenge describes hidden impacts of trauma, such as having an “all or nothing” approach to learning and relationships, not being present in the classroom (spacing out, being reluctant to participate), living in crisis mode, being unsure about who to trust or how to set boundaries, and having trouble with, or being reluctant to, set goals. One aspect of working with people who have experienced abuse is to know how to react to disclosure.  An important contribution of this sourcebook is that it gives guidelines for understanding and dealing with these issues and for setting up a support structure to help practitioners.  As with the Changing Paths program, Take on the Challenge promotes and gives guidelines on ways to bring the “Whole Person” to learning. It draws on teachings from the Aboriginal Medicine Wheel, Buddhist mindfulness and meditation and provide tools, approaches and resources that will help us to bring balance into learning and to heal each part of the self: the spirit (crushed), the emotions (overwhelmed by fear, panic,sadness), the body (wounded) and the mind (limited by people who said she was stupid) (Morrish et al., 2002: 17). This review of educational materials used with homeless people, women in conflict with the law and women living with violence has provided ideas, activities, approachesand philosophies that are congruent with a Harm Reduction approach to learning. With this information, I can go on to describe the research I conducted. But first, I will re-visit the research questions to remind myself what lessons have been learned.  Final Lessons from the Literature What is Harm Reduction? Because I work closely with programs around the Downtown Eastside, I am familiar with many of the kinds of Harm Reduction services described in the literature. Many of thelearners I work with are peer workers in needle exchanges, alley patrols, and at the supervised safe injection site. They conduct workshops on Hepatitis C and HIV-AIDS. I know the street nurses and drug counsellors, and have participated in programs promoting safer sex, safer drug use and holistic medicine. I was heartened that our programs are on the right track with our flourishing peer programs.  Improvements….No Less than Heroic 36                   It was reassuring to learn that Harm Reduction does not conflict with abstinence – infact, it can work in partnership. Literacy practitioners can support participants who want to get off drugs or out of a violent relationship, but also discuss how to use drugsmore safely or help learners to make a safety plan for their current living situation.  The literature also confirms that practitioners need to constantly listen to learners to find out what aspects of Harm Reduction are most important and useful to them. What I learned from this ongoing listening is part of the research reported here.  What was new to me in the literature was the detailed discussion of addiction, and the fact that drugs can have positive and neutral effects – they are not all bad all the time.  How does Harm Reduction link to learning? Table #1, on page 37 shows principles and practices taken from selected Harm Reduction and Literacy programs. Some of these common principles are:  being inclusive, respectful, and non-judgemental x  encouraging participation/giving users/learners a voice x  safety x  holistic approaches x  user-centred: affirming drug users and other program participants as primary agents x  recognizing and addressing poverty, violence, past trauma, racism, exclusion and vulnerability. Another comparison of  Harm Reduction and Literacy is provided in Table 2,Comparison of  Progress Criteria in Harm Reduction and Literacy (page 38) . This shows the “three stages of building stability” in Harm Reduction programs (Murray & Ferguson, 2003) next to the stages that learners and peer tutors go through as they make progress in non-formal literacy outreach programs. The literacy part of the table comes from research we at Capilano College did as part of a collaborative provincial project to develop outcome measurement frameworks, and create tools that measure progress. (Alderson, Alkenbrack, & RiPAL-BC, 2007)How can community colleges like Capilano and our communitypartners support harm reduction in our learning activities? To be most effective, I need to constantly educate myself about the struggles that learners face, how these challenges affect learning, and the role that learning takes in their lives at different times. I can do this by continuing to read the literature that Harm Reduction workers produce, and also by listening to the experts: learners, street-involved users, peer tutors and other Harm Reduction workers (program workers, street nurses, counsellors, etc.). Improvements….No Less than Heroic 37               It is clear from the literature that there is an ongoing debate about when it is best for program participants to engage in programs. Do we invite learners into the classroom before or after they have: x become drug-free? x exited the sex trade (or stated their intention to do so)?x left an abusive partner?x found stable housing?Does literacy and learning happen at the beginning or end of their healing journey, or along the road, off and on?  In our programs, and in keeping with Harm Reduction principles, this needs to be the learner’s decision – although we respect programs that cater specifically to people who have already made changes in their lives. We will always invite learners in, and it is up to them what they do with the time, and how long they stay. Most if not all approaches that work in Harm Reduction are readily transferable to literacy work. The approaches that keep surfacing are: creating a safe environment for learning, teaching and learning in a holistic way that honours the learners’ knowledge and culture, promoting peer workers or tutors and recognizing “literacy moments” as legitimate and useful to learners.  Improvements….No Less than Heroic 38     HR approaches used by Toronto Programs (Murray& Ferguson, 2003) Principles of Literacy with Homeless People (Trumpener, 1997) Features of “Changing Paths” Program (Sochatsky & Stewart) Programs that support learning for survivors of violence (Morrish, Horsman & Hofer, 2002)  - user-centred  - focused on long-term relationship-building: non-judgemental, caring, inclusive - community-development oriented - integrative, holistic and asset-building - strategic -- aimed at povert  yreduction and challenging current policies and systems  - recognize the right to comprehensive, non-judgmental medical and social services for all - supports a learning environment in drop-ins or shelters. - is inclusive and participatory. - values and builds on participants' knowledge, experience, and voice. - is critical and empowering. - is relevant - is equitable and accessible - emphasizes social and emotional needs as well as academic skills - works best with   learners whohave a stable living environment for at least 45 days - staff have experienced homeless-ness, or were active in homeless communities - Participatory- Holistic - Humanist - name the presence of violence in many women’s lives and its impact on learning Integrated Literacy and Lifeskills: - safe environment - group ground rules - create supportive conditions for learning pr- being es  ent - explore curriculum that invites            learners to bring their whole selves to learning.  -     listening                                    -  talking about the process o  fcreative writing, - women to write, speak  and connect to themselves through writing.  Harm Reduction: (Harm Reduction Coalition, http://www.harmreduction.org) ƒ  Accepts, for better and for worse that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them. ƒ  Understands drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviours from severe abuse to total abstinence, and acknowledges that some ways of using drugs are clearly safer than others.  ƒ  Establishes qualit  y of individual and community life and well-being--not necessarily cessation of all drug use--as the criteria for successful interventions and policies.  ƒ  Calls for the non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing attendant harm.  ƒ Ensures that drug users and those with a history of drug use routinely have a real voice i  n the creation of programs and policies designed to serve them. ƒ   Affirms drugs users themselves as the primary agents of reducing the harms of their drug use, and seeks to empower users to share information and support each other in strategies which meet their actual conditions of use.  ƒ  Recognizes that the realities of poverty, class, racism, social isolation, past trauma, sex-base  d discrimination and other social inequalities affect both people's vulnerability to and capacity for effectivel  y dealing with drug-related harm.  ƒ  Does no  t attempt to minimize or ignore the real and tragic harm and danger associate  d with licit and illic  it drug use.  Improvements….No Less than Heroic 39 Table 1: Principles and Practices in Harm Reduction, Literacy and Learning   Improvements….No Less than Heroic 40                                             Table 2: Comparison of Progress Criteria in Harm Reduction and Literacy 3 Stages of Foundation Building (Murray & Ferguson, 2003)Crisis Management Foundation Building Engagement Emerging Peer Tutor in a Group Setting (RIPAL-BC/ Carnegie/ Capilano, in press) Non-Participation Thinking About Learning Engaging Modeling Mentoring/ Encouraging Teaching Individual Learner in a Group Setting Rubric (RIPAL-BC/ Carnegie/ Capilano, in press)Avoidance Exposure Engagement Skill Development Challenge                                                                             PART TWO: RESEARCH ON HARM REDUCTION AND LEARNING IN VANCOUVER’S DOWNTOWN EASTSIDESome of us have just hit hard times and are doing the best we can, without going out and bothering other people. So, until you’ve met us, please don’t think that we are all bad. A lot of us have a lot of good in us. If you treat us with respect, you’ll be treated with respect in turn. (from “Look before you leap to conclusions (Andy in UpWords 2(2), July 2006)From our review of academic and practitioner-based literature as well as of the writing by program participants like Andy, we can see that respect, and looking for the good inpeople, are indeed cornerstones of Harm Reduction. In our research we went on to look more closely at the links between Harm Reduction and learning – specifically literacy and Adult Basic Education learning.  In this second part of the report, we describe this research. First we describe the methods we used, and then our findings. The findings are organized to answer our three research questions:1. What is Harm Reduction and how does it affect Downtown Eastside residents who engage in high-risk behaviours?  2. How does Harm Reduction link to learning? 3. How can Capilano College and our partner learning centres support harm reduction in our learning activities? Research MethodsData Collection To conduct this research, we gathered data through focus groups, practitioner reflection and document reviews. These are explained in more detail below.  Data Source 1: Focus groups 20 participants attended two focus groups conducted at the WISH learning centre.  These were all women, ranging in age from mid-20’s to mid-40’s. All were both current or former sex-trade workers and regular users of WISH services (drop-in, shower, dinner). Twelve were regular participants in the WISH learning centre and at least 10 were active in WISH committees and projects. Two have since gone on to become members of the WISH Board of Directors.8 All were current or former drug-users. Most 8 In 2006, a bylaw was enacted that reserved three seats on the Board of Directors for women who use WISH services, to be elected by other WISH participants. At the 2007 AGM, the first three WISH participant-Board members were elected.  Improvements.. No Less than Heroic 41                of the learning centre “regulars” knew me (the researcher) because I teach there once a week. These meetings were recorded, and one of the participants was paid to take notes. Each participant was provided with a list of the questions we would be discussing and some of the women asked to write answers to the questions in addition to participating in a Focus Group (these responses are recorded as “Focus Group Written Responses”).  A third group met at the LifeSkills Centre, and consisted of 7 members of the Editorialteam of the UpWords newsletter. UpWords is produced twice a year in order to raise awareness and engage in debates related to stimulant use and the rights of drug users. Six of the participants in this meeting were men.  All were current or former drug users and most were active in peer support groups for drug users and/or groups that promote harm reduction and drug-users rights. The Lifeskills Centre has a close connection with the Safe Injection Site, and many were current or former users of that centre. This is a group I had worked with over a six-month period, so most of the members knew me. One of the participants took notes at this meeting, but the group did not give permission to tape it, so I also took notes.All participants received honoraria, and snacks and drinks were served at the meetings.  In choosing focus groups, my colleagues and I were influenced by Geoffrey Mills (2003), who describes the method as “a particularly useful technique when the interaction between individuals will lead to a shared understanding of the questions…(p. 62), as well as by George and Greg Dimitriadis’ (2005), who describe how Paulo Freire and Jonathan Kozol used focus groups for “imagining and enacting the emancipatory political possibilities” (p. 889). I hoped we could do that in our focus groups: imagine together what Harm Reduction might be and how we could make a better contributionto it. But as a teacher, I also hoped the interaction that happens in focus groups would be more interesting for the participants, and that they would learn from the experience. I think this might have been true for some of the women at WISH. One of the participants commented that: It was the first time in a long time that I was able to express this in a legiblemanner” (Focus Group #2)  At least six participants began using the learning centre regularly after the focus group meeting, having seldom done so before:  Betsy: I see some faces here that I haven’t seen in the Learning Centre. Can you  tell me why you don’t come in?  Jane: Before I didn’t know what was happening here, and I was too shy to come  in.  Betsy: Will you come in now that you have met me?   Jane: Yes. (Focus Group #2)   Improvements.. No Less than Heroic 42                         …. and she does. Data Source 2: Practitioner Reflection  As a Capilano College instructor, I worked with two existing groups at the LifeSkills Centre: the collective that produces the newsletter UpWords and the Documentary Film Group, who were learning video production. With UpWords, I conducted writing workshops and mentored writers. With the Documentary Film Group, I provided one-to-one support in script-writing, proposal-writing, computer use and time management.  Inaddition, I provided three writing workshops for the Women’s Wellness Group, which exposes participants to health information, alternative health practices (massage, aromatherapy, etc) field trips and a community kitchen. The workshops were well received, and provided a chance to connect with women I work with in other centres in the community. I kept records of group activities and group ideas in the form of flip-chart notes and notes taken to accompany the WISH sign-in sheets. I also recorded my ideas in a journal after each session. The first set of data was quite factual, serving as reminders of what actually happened in learning sessions, while the journal notes were more reflective, and made clearer links to the research questions.Data Source 3:  Documents The following documents were used to shed additional light on our research: - UpWords, the newsletter produced by a collective or volunteers from the Stimulant Discussion Group organized by The Lifeskills Centre, Issue #1, Volume #1 (September 2005) and Issue #2, Volume #2 (July 2006). - Minutes from meetings of the UpWords editorial committee. The UpWords group members are both learners (as new journalists) and teachers (educating other drug-users and the broader community with their newsletter).- The WISH Newsletter (re-named WISHful Thinking) from 2005-2007 We used these methods to investigate our three research questions: 1. What is Harm Reduction and how does it affect Downtown Eastside residents who engage in high-risk behaviours?  2. How does Harm Reduction link to learning? 3. How can Capilano College and our partner learning centres support harm reduction in our learning activities? The report on findings consists of three sections, each one describing what we discovered about these questions. Improvements.. No Less than Heroic 43                                                            Data Collection Issues Margaret9 read the consent form out loud and everyone filled it out and handed it in. A comment was made re “Are you researching us?”  Betsy answered that she was just trying to get feedback and information on how learning is linked to harm reduction. (minutes from Focus Group #1, WISH drop-in, Oct 12, 2006) The research participant who asked this pointed question has probably attended quite a few focus groups, done many surveys, and maybe an interview or two. When she asked “Are you researching us?” she may or may not have been kidding. I have heard quite a few residents say the area is “researched to death”. So it was with some concern that I came to them with yet another research project.  But in initial discussions with some of the people I interviewed, I found that Harm Reduction is a topic they know quite a bit about and were quite keen to share their knowledge. In addition, many of the participants had participated in focus groups or interviews before, so were comfortable with the process. This, combined with thehonoraria we offered, meant there was no shortage of eager participants.  The opening comment raised another concern for me: How effective would I be as a researcher when I had already developed relationships with the participants as an instructor, workshop leader or mentor? There are two sides to this story. The first one is that, as an instructor, in spite of my best efforts to be participatory and respectful, I hold a certain amount of power in the learning centre.  Research participants may provide answers that they think will please me.  They may be reluctant to voice criticisms. This may affect the quality of data collected. (And to be frank, I would have liked to hear more criticism). On the other hand, research participants may feel more comfortable talking to me because they know me and I have “paid my dues” in the community.  Another concern is the fact that the participants got paid. Paying people small honoraria for participating in surveys, focus groups and meetings is very common in the Downtown Eastside. While some of the participants were there because they were interested in the topic, others were there for the money. A sad reality is that we would have had trouble getting participation without offering an honoraria.  I have discussed this in more detail later in this section.  A final issue is that the role of the note-taker. The person we hired to take notes at the WISH focus group is a former regular at WISH who is active in a lot of community arts organizations. The note-taker in the UpWords focus group is the secretary of the group who takes minutes at their regular meetings. I think both brought a special “insider” perspective to recording these meetings.  All of these issues affect the quality of the data, and you, the reader will have to be the judge of the effect they have had on the research.  I can say that conducting this 9 Some of our research participants asked to be referred to by pseudonyms.  Improvements.. No Less than Heroic 44                   research has been very exciting for me and I agree with BC practitioner Paula Davies that, Engaging in practitioner research has brought an amazing new dimension to my classroom practice. In fact, I would say that practitioner research is one of the most productive professional development activities that an instructor can engage in! (Davies, 2006: 4) Data AnalysisI analyzed the data using the qualitative data analysis software, Atlas ti. I then wrote up the first draft of the report. Diana looked through the rough data and compared it with the draft report, making suggestions about which aspects I had missed or needed more emphasis. When I tried to make sense of the data, I went back to the literature.  In particular, I used the “3 Stages of Foundation-building” described in Engaging Users, Reducing Harm(Murray & Ferguson, 2003) -- crisis management, foundation building and engaging -- to frame the findings for Research Question #1.   Research Findings 1. What is Harm Reduction and how does it affect Downtown Eastside residents who engage in high-risk behaviours? Defining Harm Reduction I started each focus group by asking one or two participants to read the definition of Harm Reduction copied below, which had been adapted from definitions in the literature. I wanted to make it brief and clear, and also to encompass the different kinds of risk-taking (often not included in drug-related harm reduction definitions). Then I asked for reactions from the group.(See Focus Group questions, Attachment A)Harm reduction is for people in our communities who do risky things. Some of these risks are: - using drugs- practicing unsafe sex - working in the sex trade - living with violence We accept, for better and for worse, that these activities are part of our world. We do not ask people to stop doing them, but try to help them be safer, take control and make changes only when they are ready.  Improvements.. No Less than Heroic 45                                                                                        Focus group members were mixed in their responses. Some liked the definition becauseit was “straight up, to the point” but one member felt it was incomplete, and would be better if more aspects were itemized and more specific to the Downtown Eastside.  All participants had a lot to say about what harm reduction meant to them, and the strategies they used to reduce harm in their lives. They discussed safer drug use, safety on the streets, safer sex, health and mutual cooperation. For a complete list of harm reduction strategies discussed by participants, see Attachment B.Crisis ManagementAngel: Hustle, hustle, hustle, I’ll trade you this, I’ll trade you that. Margaret is actually the first person I saw down here. (I’m going to cry now) she is the first person who protected me at the Women’s Centre when I got in an altercation with one of the girls.  I didn’t know the protocol of how to exist down here.(Focus Group #2) According to Murray and Ferguson, the “crisis management” stage is characterized by depleting assets, living in crisis and cycling in and out of chaotic use.  Initialcontributions to our Harm Reduction brainstorms usually had to do with activities related to physical and health needs. For example, people talked about getting enough food, finding a place to sleep or live, cleanliness and having the means to clean themselves. Others talked about health care issues, such as having access to an ‘experienced, certifiable care-giver” and medical facilities available 24 hours a day so you won’t have to go to the hospital or spend hours on Fastrack”10 (Focus group #2). One participant talked about her involvement with the Dr Peter Centre, a facility for HIV and AIDS patients. (Focus Group written responses) Physical needs are important, and many people spend a huge amount of time looking for food, clothes and a place to sleep. But they also talked about paying attention to their mental and emotional health. Here are some examples:  x  “I like to keep busy” x  “When I’m going out to work I think about looking for flowers and not just about how I need money and drugs.” x  “Stick to your moral values” x  “I keep my own personal agenda” (Focus Group #2) x  “Stay away from unhealthy relationships, men or women.”  10 Fasttrack is a central phone number set up to refer drug-users to detoxification centres and rehabilitationprograms. At the time the research was being conducted, many participants said they had to wait a longtime to speak to a counsellor and often did not get the help they needed.  Improvements.. No Less than Heroic 46                        x  “I try not to bring much stress into my life or try not to analyze much of the stressful things that transpire in my daily life or with my current boyfriend.”(Focus Group written responses) Foundation Building Journal Entry I got a call from “Carol” on the weekend. She was in detox – Wow! I hadn’t dared to hope that she would make it, even though we had talked about it at the learning centre during the week, and the visiting street nurse had found her a bed. She asked me to come and visit, but unfortunately I wasn’t able to get there until today (Monday). They said she had checked herself out. Tonight she came into the learning centre and gave me a longer-than-usual hug. “I failed”, she said, “I couldn’t make it”. Carol was not a failure – the act of going to a detox centre was a big step. She was indeed building a foundation. Our Focus Group participants confirmed that Harm Reduction is not an “all or nothing” thing. They talked about “slowing down” and tryingto keep off drugs, or off the street.  “Trying” is the operative word. “I do the best I can at refraining from turning to the sex trade.”“I try not working the streets too often, and when I do I try to practice safe sex.” (Focus Group written responses) “I try to keep drug and alcohol use to a minimum, not every day.”  (Focus Group #2) But also, as many people who write about Harm Reduction have said, drugs and alcohol are not all bad, which is why the abstinence-based programs often do not work for them. Karen spoke about how each one of us chooses our own paths in life and that she would have jumped off a bridge long ago if she had not had alcohol or drugs to help her cope.  It’s a coping mechanism. We came to the conclusion that harm reduction means that it is recognized that people do need drugs to cope attimes and it is a reality of life. (Focus Group #1) EngagingThis is the stage where users begin to build assets, improve their quality of life, become more self-directed, and connect to the community and economy – perhaps by attending community programs and volunteering.   The research participants who came to Focus Groups at the WISH learning centre were not all active members or learners there. In other words, they did not necessarily Improvements.. No Less than Heroic 47                   “engage” in community groups or volunteer work. But almost everyone mentioned theneed to cooperate, and how they did their part in large and small ways. They mentioned strategies such as joining a program, volunteering, and “having a positive interaction in the community” (Focus Group # 1 & 2). Many research participants have told me, in words and actions, that harm reduction isnot only about keeping yourself safe, but also about helping others in the community to stay safe, bringing joy to their lives, and getting involved in Harm Reduction groups.   “Sometimes other women do not have any condoms and ask for them. I try to help those who ask.” (Focus Group written responses) “I like being part of WISH” (Focus Group #1)“We want to contribute to the community” (UpWords focus group) Some women at WISH talked about volunteering on community boards.  Since our focus group, at least two women from WISH have joined boards in the community and three are on the WISH board.  This poem, in the second issue of UpWords, is a contribution by a member of the editorial group who is very active in the community: Maintaining Street Lights Harm reduction is not only handing out rigs, mouthpieces or condoms.  But helping a person lying on the ground. Taking the time to talk to someone who is lonely or hurting,  Whether the sun is shining or it is pouring rain.  Pushing a person in a wheelchair up a hill.  Saying good morning or hello to a passer by.  Showing empathy and compassion to our fellow brothers and sisters.  Dave Apsey An “Engaging” Group: The UpWords Newsletter Team The UpWords editorial group is an excellent example of a group that is taking collective action to “engage”, making a contribution to their community and building personal assets in the form of skills and a social network. In this section I describe the group and issues that are important to them, using their writing and discussions in the Focus Group. Three descriptions of UpWords:Coco Cuthbertson, Lifeskills Director, described UpWords as “a voice for those who have few places to tell their stories and share their real challenges of living with a drug Improvements.. No Less than Heroic 48                        addiction and writing about the culture that surrounds it.” (“Welcome to UpWords”, UpWords 1(1) September 2005). Two participants made the following contributions to the UpWords mission statement: 1. UP-WORDS is a group of stimulant users, united in the education and well-being ofall stimulant users, whether male, female, young or old. Putting our minds and our hearts into making the stimulant users’ world a better place.(source) 2. UP-WORDS is a group devoted to getting respectful, accurate information regarding stimulant use to users, decision makers and the public at large. (authors unknown, UpWords minutes, June 21 05) Participants in the UpWords Focus Group described it as “street-involved people recording what is happening in the community” and “seeing things through the eyes ofstreet-involved people”.  Why is UpWords specifically for Stimulant-users? I asked this question, hoping to learn more about the reality of drug users – why would there be a special group for people who use stimulants (Cocaine and Crystal Meth)? They said: “Stimulants make you more active” “There are already lots of support groups for methadone/opiate users, butthere are more stimulant users in the Downtown Eastside”  In the course of answering this question, they also identified concepts that are centralto Harm Reduction philosophy and practice:   “There are lots of groups for stimulant users who have quit or want to quit. We are different. We say we like using it, now how can we make it safe?” “We have proven that stimulant users can still get involved.” Why is UpWords Important? I asked the editorial team this question in hopes that they would help me to understand their perspective on Harm Reduction. I was not disappointed. While one of the participants talked about personal benefit (“The group keeps me busy – I am not out doing crime”), other responses showed that a lot of thought was going into how thegroup could benefit the wider community:  “People drift into the centre due to poverty.  This group can give them a sense of knowledge and purpose” Improvements.. No Less than Heroic 49                                                                   “The group builds cultural bonds. People from different cultures work as one group. This helps us to understand each other, where we come from and why we do things the way we do.” “When I listen to people talk, it is pretty deep. People talk philosophically. We need to encourage them to get these ideas down on paper.” “We are changing attitudes towards the neighbourhood, helping to dispel myths, debunk stories: this is empowering!” “We want to contribute to the community”For a sample page from UpWords, see Attachment D. Yes, but -- Engaging while in crisis: Journal Entry When I came out of the workshop, I saw J. hanging around the lobby of the  Lifeskills Centre. She had obviously just come out of the shower.   Me: “What’s up?” (after the usual hug).   J: Oh, I’m waiting for my laundry”.   Me: “I thought you had washing machines at your place?”  J: “We’re not there anymore. Me and G. have been living on the street for a month” This would not be an unusual story, except that J. is an active volunteer in a number of organizations, and in particular was very involved in this year’s “Learner to Learner”11 project at WISH, in which the women distributed carepackages to other women on the street.  So she was doing outreach to women while she herself was in need. This story is typical.  Many people I work with are both active in organizations (the“engagement” stage) and homeless or dealing with some kind of crisis related to drugsor violence. J. was not only an active volunteer in the community, but learning how to make videos and other digital media. This does fit with what Murray and Ferguson’sfinding that people cycle back and forth between stages of foundation building, but J.’s story conflicts with the idea that they can only begin to expand their horizons once the means of survival are in place and  with Trumpener’s recommendation that “learners have a stable living environment for at least 45 days” (Trumpener, 1997: 54) 2. How does Harm Reduction link to learning? Participants made several connections between Harm Reduction and Learning. These include: learning about Harm Reduction, judging the quality of those learning 11 A provincially-funded program which encourages learners to apply for a small grant and organize a project each year. Improvements.. No Less than Heroic 50                                                                                   experiences, getting trained (with or without certificates) to teach others about Harm Reduction, participating in high school upgrading and other courses, joining programs designed especially for them, such as the PEERS program12 and participating in informaldiscussions about topics related to Harm Reduction.  Star: As an injector, I’ve learned at least five things (from the nurses at InSite)that helped me and then I can suggest them to other injectors. (Focus Group #1) The Harm Reduction literature is full of useful information about helping street-involved people to learn about harm reduction, and there are lots of such activities inthe DTES. Star’s comment is an example of how participants are not only aware of their own learning, but is also willing to take on the role of teacher/mentor on specific issues. Similarly, Angel said: Better certified education equals better harm reduction and hopefully being able to help another user by educating them. (Focus Group written responses) Focus group participants had suggestions about how learning could contribute to betterharm reduction. For example, they suggested workshops on various aspects of Harm Reduction.In most cases, learning about Harm Reduction was described as separate from the other kinds of learning people do at Learning Centres in the Downtown Eastside. They mentioned educational games, like word bingo, learning a new craft, the Book Club and reading the newspapers. Some expressed interest in more formal education:  - working on my GED - formal training, and more professionals coming into the learning center - “More follow-up, that it is not big in this town.”  - “I need to be pushed more.”- “I need more direction.”A few people asked for information on other programs. For example, Karen talked about how much the PEERs program was helping her (she found out about it at WISH).   They also had ideas about other kinds of learning: attending school for a couple of hours a week; attending information sessions on education and housing; learning computers and outings which “get you away from the area and give you spiritual enlightenment” (Focus Group #2). One Focus Group participant said,  Attending new functions and workshops helps me to be able to communicate and feel cohesive and highly functioning. (Focus Group written responses) For a complete list of suggestions about educational services, see Attachment C.  12 PEERS is a program designed to help women and men who want to get out of the sex trade.  Improvements.. No Less than Heroic 51            UpWords team have engaged in discussions about issues that relate to Harm Reduction. For example, when describing the UpWords work, one participant said: “This group creates a connection – along the lines of Bruce Alexander’s ideas about addiction linked to disconnection. UpWords fills a void.”(UpWords Focus Group) Articles in the newsletter show clearly that the writers have done their homework. Here are two examples:  Crystal Meth is a stimulant that looks and acts like a neuro-transmitter. When neuronsin the brain absorb the drug, the natural neural transmitters are pushed out and replaced. When these chemicals (primarily dopamine, serotonin, and norepinephrine) are released into the bloodstream, they start “talking” to the rest of the body. (“Crystal Meth surpasses other drugs”, by Dave Apsy, UpWords 1(1) September 2005) Legalization of prostitution has been proven in most European countries. Once legal, the violence and abuse reports have decreased by 63%, proving that legalization works. (“Legal Protection Needed for Sex Workers, by Tammy Sherar. UpWords 2(2) July 2006) 3. How can Capilano College and our partner learning centres support harm reduction Harm Reduction Principles It seems like a good starting point for this discussion to look at how our teaching is inline with Harm Reduction principles. We start with the definition we gave to the focus groups:  We accept, for better and for worse, that these activities are part of our world. We do not ask people to stop doing them, but try to help them be safer, take control and make changes only when they are ready.  … and add the conclusion that one of the focus groups came to:  We came to the conclusion that harm reduction means that it is recognized that people do need drugs to cope at times and it is a reality of life. ….and finally the observation from the UpWords team:  There are lots of groups for stimulant users who have quit or want to quit. We are different. We say we like using it, now how can we make it safe? All of these elements are linked to acceptance, respect and giving learners a voice – things that literacy practitioners are already very good at. However, as Alderson and Twiss said in Literacy for Women on the Street: The pitfall is that you can become attached to your expectations as women make progress, attend regularly and appear enthused about their learning. When women suddenly stop coming or get heavily back into drugs, it is easy to feel Improvements.. No Less than Heroic 52                  disappointment as literacy instructors and to wonder if we are making anydifference. (Alderson & Twiss, 2003: 52) Another challenge for literacy practitioners, programs and funders is the difficulty to show “progress”, justify our existence and, as Betsy Trumpener (1997)says “speak the language of the marketplace”. A series of “unsuccessful” attempts to get off drugs isnot on a list of typical “indicators of success” and Carol (the woman trying to succeedat detox, described in the journal entry above) is still a long way from being successful in the market place. However, according to Harm Reduction principles, Carol is a success. If we are going to contribute to Harm Reduction we need to adjust our attitudes and describe what our learners are doing in a way that emphasizes that success. Institutions and funders need to adapt their measurements to recognize that learning is not linear.Bread and Roses ‘‘ Our lives shall not be sweated from birth until life closes; Hearts starve as well as bodies; give us bread, but give us roses.‘‘(James Oppenheim published in American Magazine in December 1911) This line from a song I sometimes sing on International Women’s Day gained new meaning when I started to notice how service workers operated in the Downtown Eastside. They pay attention to the “bread” -- the food, clothing, shelter that many residents look for so diligently, but also to the “roses” – enjoyable, sociable, mind-expanding activities that sooth the body and the soul. For example, at the LifeSkills Centre, people can come in for a meal, to do laundry or to get information – but they can also attend art classes, go on an outing or participate in a women’s wellness group. They are working to meet physical, emotional, and spiritual needs. By spirit, we do not mean promoting a particular religion, but “lifting the spirit.”  Karen: “It builds up my spirit when I come here and gives me a bit of time to myself before I go back out into the world.” (Focus Group #1) This is also about “bringing the whole self into learning” (Horsman, 1998; Morrish et al., 2002) which we have found to be essential at WISH.  Research participants had quite a bit to say about this. They participate enthusiastically in “Beauty Night” (where beauty and health practitioners provide free haircuts, facials, pedicures and massages), pajama parties and karaoke nights. They also talk about the need to heal and expand the mind:  Frances: To be healthier, I would like to see a peer help me get to  psychotherapy.  Kayla: (Working in a group) allows me to broaden my own skills and abilities to afurther spectrum than it currently is, to allow myself to learn more than I Improvements.. No Less than Heroic 53                  currently know at the present moment in my life, to remain open and not to shut down on the inside of what it is I’m wanting to learn to contribute to the group I’m in at the moment. (Focus Group written responses)One woman even mentioned the focus group as an example of an activity that encourages thinking!  These ideas also came out when we had a discussion about how the WISH learning centre was different from the main part of the drop-in:Here (in the Learning Centre) there is emptiness and peace and quiet, tea, and you can work on your GED. Margaret said that she feels more relaxed in this room. Over there (in the main section of the drop-in), there is a lot of bickering and it’s more like a flophouse.  You can have a conversation in here.  It is more civilized and formal in here.  You don’t get yelled at in here or spit at or sworn at. There is more fighting over there.  Here you learn how to relax.  It gets our mind out of the gutter. You ask us how we’re doing, and show concern about the different things we do during the day. (Focus Group #1) Participants were quite clear that their self-esteem needed to be built up, and really appreciated the efforts that were made by different programs in the Downtown Eastside. For example: Frances spoke about her experience with living with violence and how acounsellor had helped her with her self esteem and helped her to leave a cruel and violent man.  “I have to hand it to WISH: I joined Colette’s group (The Aboriginal Health and Safety Project) for sex trade ladies and we met Tuesdays and Thursdays. They helped me with my self-esteem and my sick way of thinking. I was with a very cruel, violent man and I stayed with him for two years. My life was hell and I thought something would change, but it just gotworse. So that’s what I think of when I see this “living with violence”. WISH has helped me, it helped me with my self-esteem and it helped me to get back into the right place. Especially when you’re using – it could be drugs or alcohol. Even a big ego – you don’t have to do drugs or booze. It’s just getting down and being humble to yourself.” The group thanked her for sharing her story. (Focus Group #1) As important as the “roses” are, we have also found that programs do not survive if we ignore the “bread” – and we mean that literally.  The welfare and disability incomes that most downtown eastside residents collect are not nearly enough to survive on in Vancouver.  For example, until recently, single 'employable' adults aged 18-64 received a benefit rate of $510/month ($325 for shelter and $185 for other living expenses, which amounts to $6 a day). With the 2007 budget, these rates were raised to $610,with $375 to be paid for shelter and $235 for other expenses. Also, while the total rate for single clients who are expected to work increased by $100 per month, the rate forcouples increased by only $50 per month. This rate is still woefully inadequate for Improvements.. No Less than Heroic 54                                                                         someone living in Vancouver, so it is essential for them to supplement their income using the food bank, lining up for free meals, finding free clothes, working in the sex trade, etc. (and because couples get less, they may feel forced to live separately even if they want to be with their partners)13 Most participants expect an honorarium (usually between $3 and $10) for participation in groups.  Food is also appreciated, and in some cases, required. As a member of the UpWords team said, It is great to see people coming back because they want to be part of the group, not just for the money – but people also need to be paid for participation. (UpWords Focus Group) And on good days, they can be selective: Everybody thanked Betsy for the meeting and said it was better than the Vandu survey – you only get $3 there.  All the participants collected their $10 and left. (Focus Group #1)Building connections Know that you are loved To all the women around Vancouver and the World – Feel good about yourself. There are a lot of people that love you.  Don’t forget: you’re not a punching bag.  For anyone. At all.  You have a lot to give to people.  Let someone know where you are going  and what time you will be done. Don’t forget to enjoy life.  When you see someone you know  that needs a hug, give one.  Be safe. You are loved always.  Your friend  A. WISHful Thinking, Winter 2007 13 (For details, see http://www.raisetherates.org/news/budget.html and http://www.eia.gov.bc.ca/factsheets/2007/increase_table.htmImprovements.. No Less than Heroic 55                               This poem by a woman who attends WISH is not unlike many statements of encouragement and support that women give each other.  By making these statements, women are playing a leading role in creating connections and building community. They also appreciate our efforts to nurture this. As one Focus Group participant said,  The activities that are most helpful to me build friendships and bridges among other people to help me with feelings of inadequacy. (Focus Group #2) Other comments included:  x  I know there’s a friendly face in here x  You can have a conversation in here and there is a more cooperative spiritx  I like being a part of WISH x  You can sit around the table and drink teax  I just like talking with other people  x  an ear to bend x concern from others  x opportunity to share ideas  (Focus Groups #1 and 2) Collette Schooner, who facilitates an Aboriginal women’s group at WISH, says that the main thing she tries to encourage in her groups is the idea of “sisterhood”. Graduates of her program make very positive comments about it, and have gone on to take upleadership positions in other community groups, so she must be on the right track. When I get worried that the Learning Centre is ‘too comfortable’ or that there is too much socializing and not enough “real” learning, I am reassured by reading Bruce Alexander’s and Gabor Maté’s research that indicates most of the people who come through our doors have missed out on vital connections during their lives, and if we donothing else but help them to recreate that connection, we are still doing our job.  A safe space for learningAs a way to uncover ideas about what was working (and not working) in the Learning Centre, I asked the question, “Some people I see in here all the time, others not at all? Why do you come in here and if you don’t why not?” For most of the regulars in the room, the answers were clearly linked to the creation of a safe space for learning. x  There is a better vibe in here that out there x  In the TV room everyone is fighting and in a rush to get their makeup. It is calmer and cleaner in here  x  Its quiet and nobody bumps into you in here; there’s less bickering x  It feels safe in here, and very peaceful.  x  It’s relaxing x  It’s more formal and civilized x  I can get my mind off my problems x  It’s a safe place to come, safe person to talk to Improvements.. No Less than Heroic 56                                                                            And some of the comments about what stops them from coming in can also shed light on this issue: Maybe it would take a while for me to get comfortable enough to come in. Sometimes I’m too shy to come in. If someone is really loud, or has a toxicpersonality, I stay away (Focus Group #2) The idea of providing a safe space for learning is not new to us. It is stressed in the literature reviewed in this report, and Jan Sawyer devotes a whole chapter to it in the Research-in-Practice report Hardwired for Hope: Effective ABE/Literacy Instructors(Battell et al., 2004). Asking the Right Questions One of the objectives of producing UpWords is to develop the writing abilities and produce some good reporters able to document events in our community. Recently, Betsy Alkenbrack was introduced to us, to become our mentor for this. (from “Editorial -- Food for Thought” by Hendrik Beune in UpWords 2(2) July 2006.) I worked with the UpWords group for about six months, as Hendrik says, in a mentoring capacity. And the Editorial group’s reflection on this experience shows that they experienced my participation as a Capilano instructor quite differently from the WISH research participants. They had quite specific suggestions, mainly related to support for their writing. These included: x  asking the right questions (about our writing and at workshops) x  helping us to put thoughts and ideas on paper and support people who need help with basic reading and writing x  showing us that it is easier to write about personal struggles x  editing with understanding, keeping the important stuffOne participants added: You got me back into writing again!        (Upwards  Focus  Group)  Working with Peers Journal entry: LifeSkills has asked me to do a workshop with peer tutors who want to work on a letter-writing campaign to support the Safe Injection Site14. I worked with Jessie and Sue. We discussed ways to generate ideas, using sentence-starters and how to scribe for someone who doesn’t want to write. Then we opened the doors andlots of people came in. Some of them wrote short, angry “Dear Stephen” letters, 14 In the summer of 2006, the Federal Government under Stephen Harper threatened to close down the Safe Injection Site, a place that many LifeSkills members feel connected to.  Improvements.. No Less than Heroic 57                         others were more concerned with getting the format and formal language right. But it is clear that many drug users and other Downtown Eastside residentswanted to support Insite. The tutors were great – I was impressed with how well they worked with people and how they generated ideas and enthusiasm.  Peer work is a tradition in the Downtown Eastside. Most of the UpWords group is either a paid or volunteer peer worker, and participants in all three Focus Group have taken on many different peer roles. Some of the ones I have heard about include: x alley patrols (picking up needles and garbage, getting help for those who need it x receptionists x tutors x library workers x teaching crafts and cultural activities x peer counsellors x book club organizer Focus group participants at WISH mentioned the need for peer training and the UpWords group asked for help that would make them more effective mentors:  We need more mentors for new writers: to help others to write, act as scribe orsecretary or interview them. You can help us to be better mentors: Make sure we are not writing our own ideas, but helping others to write theirs. (UpWords Focus Group) In this excerpt from an UpWords article, Dave Apsey reflects on his experience as a peer volunteer at the 17th International Conference on the Reduction of Drug Related Harm in Vancouver in May 2005: Being a peer at this conference made me think about my job as a Peer Supervisor at the Washington Needle Depot, and how it could be improved. How we can employ drugusers in a variety of tasks, from front line street workers, doing surveys, education and even counsellors. (Dave Apsey Peer Volunteers Break New Ground, UpWords 1(2) July 2006) Aside from providing financial support and training to a deserving group in thecommunity, peer programs are often praised because they make the organization more effective. As people who have been there (and often still are there) they can be more influential and sensitive than workers who have not.  So what is the role of the instructor who has not been street-involved? This conversation in one of the Focus Groups sheds some light on this:  Frances: Betsy, have you ever experienced a violent relationship or used drugs?Improvements.. No Less than Heroic 58                 Betsy: Not really, but there was lots of violence in the streets where I used to  live Johannesburg, South Africa.  And I have never used injection drugs.  Do you  think I would I be more effective if I had been a drug user?Star: If you were a counsellor, but you’re not.Angel: You’ve got empathy.Frances: I don’t care if you’ve had experience or not. You’re willing to learn as  you go along…..There are so many out there that ruin people’s lives because  they don’t have that experience, but not you. (Focus Group #1)  According to Betsy Trumpener (1997: 12) successful literacy programs serving the homeless have “staff who have experience of homelessness, or were politically and socially active in homeless communities.”As a way to compensate for our lack of experience, it is essential that we join them intheir activism – not just as a way to support them, but as a way to learn from them and become more effective in our work.  In this section I described the findings of the research on the links between Harm Reduction and learning, framed by our three research questions. The final section summarizes this information and makes recommendations for future work.  Bringing the threads together In this research project, I have conducted focus groups at WISH and the Lifeskills Centre, reflected on my work there and consulted documents. I have learned about Harm Reduction, how it links to learning and how my colleagues at Capilano College and our partner community groups can improve our practice by paying attention to Harm Reduction. Improvements.. No Less than Heroic 59             PART THREE: CONCLUSION AND RECOMMENDATIONSThis report starts with the words of Johnny Knox, who asks, “(W)ho really recognizes the true value of improvements that these people make themselves?” The review of Harm Reduction literature and discussions with research participants has helped me to understand why the changes and improvements, even the small ones, are so difficult to make, and why a person who makes the effort to break out of a high risk lifestyle is so “heroic”. As a literacy practitioner working within a Harm Reduction framework, it is up to me to recognize their struggles and successes, to start where they are and to move at their pace. Not mine, not the program’s, and not the outside evaluator’s.   So if you agree with me, let’s dream for a moment. Imagine we work in a learning program and a community that truly promotes and supports Harm Reduction. Whatwould it look like and what would we do? Here are a few characteristics that come to mind, springing from the research:  Our program staff is familiar with and committed to Harm Reduction principles and we have enough time, knowledge, resources and support (from the program and our colleagues) to practice it effectively. That means there is time for training, reflection, team-building and self-care.  A political understanding and commitment is at the root of everything we do. As Sarah Evans, InSite manager, says: “Addiction is not so much a medical issue as a social problem, with roots in poverty, abuse, neglect, racism, sexism, etc.  The root of the harm is not the behaviour or the addiction, but the circumstances that lead up to and perpetuate both.” This understanding is crucial to good Harm Reduction and good learning. The learning space is a welcoming, safe place where learners are encouraged to participate to the best of their abilities. There is joy and challenge in the classroom. We work with the whole person, not just with his veins or her brains. We ask questions and support learners in their search for answers. We promote sisterhood and brotherhood.  We are connected to and involved with the wider community, where educators, health practitioners, community workers, activists and residents share resources and ideas. There is a continuum of care and a continuum of learning. Learners can cycle in and out, back and forth, always knowing that there is a place for them, whatever stage they are at. We respect, value and support our Peer workers – whether they are tutoring in the learning centre or picking up needles in the alley. We do not see our peers as cheap labour, but as assets to the program with wisdom and experience we will never have. Inour peer training program, there is time to develop as a group, set priorities and engage in meaningful learning.  Peer workers are encouraged and supported to move into new positions, take on new challenges and move into leadership positions when Improvements.. No Less than Heroic 60                    they are ready. We recognize and address power imbalances that may occur in peer/non-peer work relationships and engage peer workers in a way that is meaningful and useful to them.  This dream seems to in line with advice from Gabor Maté: “If you want the addict to say NO, first you have to give her something to say YES to: connection is possible without drugs, love is possible without drugs, success is possible without drugs” (presentation to Carnegie Community Centre staff, December 2006).   We might add…. Connection is possible off the street Love is possible without violenceSuccess is possible outside of the sex trade.  That is the dream. The following recommendations will help to make it come true.  Recommendations For Adult Literacy/ABE Practioners 1. Recognize that getting off drugs/ out of the sex trade/ away from a violent relationship is difficult, frustrating, long-term work. Learn how these challenges affect learning and how you, the educator can best support the learner. 2. Find out from learners what the learning space should look like. What would make it welcoming and safe? What resources should be available? What activities? How can you involve the whole person in learning? 3. Encourage your organization to provide training in harm reduction principlesas well as strategies for keeping people safe when engaging in risky behaviour.4. Educate yourself and your colleagues about the reality of your learners’ lives. If they have turned to drugs to help them make sense of a senseless situation, what needs to happen to turn that situation around? How can you support that change in your learning centre?  5. Working with street-involved, drug-using learners is difficult, stressful work. Recognize this, take care of yourself and demand that your organization supports mental health and self-care for their staff. 6. Learn from those who work on the “clinical” side of Harm Reduction by building partnerships with people in the health field, including mental health and drug/alcohol counselling.  7. Just as you learn from health care workers, they can learn from you. Helpto raise awareness about literacy issues in the community and help other organizations to make their messages accessible and inclusive. Make sure learning is on the agenda at community events. Improvements.. No Less than Heroic 61                  8. Connect with other learning organizations in the community. Share information and develop referral strategies that provide a continuum of learning. 9. Seek out opportunities (conferences, workshops) to share ideas with other practitioners trying to adapt HR principles to the literacy situation.  10.Pay special attention to peer learning and promote/support your peer volunteers. When possible, encourage peers to apply for paid work in your organization. 11.Look for and develop materials and activities that reflect the reality of thelearners you work with, and materials that emphasize the whole person. Support organizations that develop materials on violence and learning, addiction, Harm Reduction and related issues.  12.If we are going to contribute to Harm Reduction we need to adjust our attitudes and describe what our learners are doing in a way that emphasizes their success. Find ways to measure progress that takes account of on-linear learning and small steps. For Funders and other Decision-Makers 1. Support, promote and encourage everything listed above! 2. Given that only 5-10% of the drug-using population is prepared to consider abstinence-based programs (Riley & O'Hare, 1999), Harm Reduction is a rational approach to promoting healthy communities. Program approachessuch as those listed above should be promoted and supported.  3. Implement funding requirements that reflect Harm Reduction principles rather than requiring a "one size fits all" approach that bears little resemblance to local realities. 4. The practitioner described in this research report is typically skilful and committed, but also doing work that is subject to a high rate of burnout. Make it possible for programs to offer good salaries and working conditions so that practitioners will stay on the job. In this way, programs and learners will benefit from their knowledge and he field will grow.  5. Support training, networking opportunities and exchanges between programs using Harm Reduction approaches.  6. Recognize that learning is not linear in Harm Reduction contexts and support the development of measurement strategies that take account of this. Improvements.. No Less than Heroic 62                 FOR FURTHER READING/SURFINGDr Gabor Maté http://www.drgabormate.com/ghosts.php  InSite http://www.communityinsite.ca  Learning and Violence http://www.learningandviolence.net/  Literacies Journal http://www.literacyjournal.ca/  Living in Community: Balancing perspectives on  Vancouver’s sex industry  http://www.livingincommunity.ca/  Medically supervised injection centre, Sydney,  Australia  http://www.sydneymsic.com/  Research in Practice in Adult Literacy BC  http://ripal.literacy.bc.ca/whoweare.html  WISH http://www.wish-vancouver.net/Improvements.. No Less than Heroic 63        REFERENCESAlderson, L., Alkenbrack, B., & RiPAL-BC. (2007). From the Ground Up.  Retrieved 06/02/07, 2007, from http://ripal.literacy.bc.ca/fromthegroundup/Alderson, L., & Twiss, D. (2003). Literacy for Women on the Streets. Vancouver: Capilano College/WISH. Alexander, B. K. (2001). The Roots of Addiction in Free Market Society. Vancouver: Canadian Centre for Policy Alternatives. Battell, E. (2001). Naming the Magic: Non-Academic Outcomes in Basic Literacy. Victoria: Province of British Columbia, Ministry of Advanced Education. Battell, E., Gesser, L., Rose, J., Sawyer, J., & Twiss, D. (2004). Hardwired for Hope: Effective ABE/Literacy Instructors. Duncan, BC: Malaspina University-College. Benoit, C., & Millar, A. (2001). Dispelling Myths And Understanding Realities: Working Conditions, Health Status, And Exiting Experiences Of Sex Workers. Victoria: Prostitutes Empowerment, Education and Resource Society (PEERS) University of Victoria. Bourdieu, P. (1984). Distinction: A Social Critique of the Judgement of Taste (R. Nice, Trans.). Cambridge, Massachusetts: Harvard University Press. Bourdieu, P. (1991). Language and Symbolic Power (G. Raymond & M. Adamson, Trans.). Cambridge, Massachusetts: Harvard University Press. Brown, L. M., & Gilligan, C. (1992). Meeting at the crossroads: Women's psychology and girls' development. Cambridge, MA: Harvard University Press. Brown, N. L., Luna, V., Ramirez, M. H., Vail, K. A., & Williams, C. A. (2005). Developing an effective intervention for IDU women: A Harm Reduction approach to collaboration. AIDS Education and Prevention, 17(4), 317-333. Cavalieri, W. (1998). Working with lives and not just veins. Harm Reduction Communication http://www.harmreduction.org/. Christensen, C., & Cler-Cunningham, L. (2001). Research report into violence against sex trade workers in Vancouver's Downtown Eastside.  Retrieved July 23, 2002 Connon Unda, & Clifford. (1997). Instructor empowerment in the Ontario Federation of Labour’s BEST project. In Taylor (Ed.), Workplace education: The changing landscape. Toronto: Culture Concepts. Currie, S., Laliberle, N., Bird, S., Noelle, R., & Sprung, C. (1995). Assessing the Violence Against Street-involved Women in the Downtown Eastside/Strathcona Community. Vancouver, B.C.: Ministry of Women's Equality, Downtown Eastside Youth Activities Society & Watari Research Society. Daum, K. (1997). A Continuum of Abuse: Yesterday's Child Sex Abuse Victims are Today's Sexually-exploited Children are Tomorrow's Adult Sex Trade Workers. Vancouver, B.C.: Downtown Eastside Youth Activities Society. Davies, P. (2006). See Me: Use of Personal Narratives in the Classroom. Vancouver: RIPAL-BC (Research in Practice in Adult Literacy). Docherty, A. (2006). Catching Our Breath: Collaborative reflection-on-action in remote-rural BC (Research in Practice Projects). Vancouver: RIPAL-BC. Edmunds, G. (1998). The Red Road. Harm Reduction Communication http://www.harmreduction.org/, Fall 1998. Improvements.. No Less than Heroic 64         Egan, J. (2003). Advocate, mentor or master? Worker-client power dynamics in HIV prevention for injection drug users. Studies in the Education of Adults, 35(2). Erickson, P. G., Riley, D. M., Cheung, Y. W., & O'Hare, P. A. (1997). Harm Reduction: A New Direction for drug policies and programs. Toronto: University of Toronto Press. Francis, D. (2007). Red Light Neon: A History of Vancouver’s Sex Trade Vancouver: Subway Books. Garcia, B. (1999). San Francisco's Treatment on Demand Guidelines. Harm Reduction Communication http://www.harmreduction.org/  Retrieved Spring 99 Graham, E. (2007). Rounding ‘em up on the East Side of the Wild West: Four Pillars, or One Big Corral? . University of British Columbia, Vancouver. Green, S. T., & Goldberg, D. J. (1993). FEMALE STREETWORKER--PROSTITUTES IN GLASGOW: A DESCRIPTIVE STUDY OF THEIR LIFESTYLE. AIDSCare, 5(3). Harm Reduction Coalition. Principles of Harm Reduction. 2006, fromhttp://www.harmreduction.orgHoddinott, S. (1998). Something to think about; please think about this.  Retrieved July 24, 2003, from http://www.nald.ca/fulltext/stta/something.pdfHorsman, J. (1996). Responding to Disclosures of Abuse in Women's Lives. In K. Nonesuch (Ed.), Making Connections: Literacy and EAL Curriculum from a Feminist Perspective. Toronto: Canadian Congress for Learning Opportunities for Women. Horsman, J. (1998). "But I'm Not a Therapist" The Challenge of Creating Effective Literacy Learning for Survivors of Trauma. Paper presented at the Australian Council for Adult Literacy 21st National Conference: Literacy on the Line, Adelaide, University of South Australia. Horsman, J. (2000). Too scared to learn: women, violence and education. New Jersey: Lawtence Erlbaum Associates. Horsman, J., & Norton, M. (1999). A Framework to Encourage and Support Practitioner Involvement in Adult Literacy Research in Practice in Canada. Ottawa: National Literacy Secretariat. Horsman, J., & Woodrow, H. (2007). Focused on Practice: A Framework for Adult Literacy Research in Canada. Vancouver: Literacy BC. Kamberelis, G., & Dimitriadis, G. (2005). Focus Groups: Strategic Articulations of Pedagogy, Politics, and Inquiry. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of Qualitative Research (3rd ed.). Thousand Oaks, CA: Sage. Living in Community Project. (2006). Living in Community: Balancing Perspectives on Vancouver's Sex Industry. Action Plan. Vancouver. Lytle, S. L. (1997). On Reading Teacher Research. Focus on Basics, 1(A). MacPherson, D. (2001). A Framework for Action: A Four Pillar Approach to Drug Problems in Vancouver. Vancouver. Marlatt, G. A. (1998). Harm Reduction: Pragmatic strategies for managing high-risk behaviours. New York: The Guilford Press. Mason, K. (2006). Best Practices in Harm Reduction Peer Projects  . Toronto: Street Health Improvements.. No Less than Heroic 65           Mills, G. E. (2003). Action Research: A guide for the teacher researcher (2nd ed.). New Jersey: Merrill Prentice Hall. Morgan, D. (1997). Writing Out Loud. Edmonton: Grassroots Press. Morgan, D. (2002). More Writing Out Loud. Edmonton: Grassroots Press. Morrish, E., Horsman, J., & Hofer, J. (2002). Take on the Challenge: A Sourcebook from the Women, Violence, and Adult Educaiton Project. Boston, MA: World Education. Murray, J., & Ferguson, M. (2003). Engaging Users Reducing Harm. Toronto: United Way of Greater Toronto. Niks, M., Allen, D., Davies, P., McRae, D., & Nonesuch, K. (2003). Dancing in the Dark. How do Adults with Little Formal Education Learn? How do Literacy Practitioners do Collaborative Research? Duncan, B.C.: Malaspina University-College. Norton, M. (2001). Challenges to sharing power in adult literacy programmes. In J. Crowther, M. Hamilton & L. Tett (Eds.), Powerful Literacies. Leicester: NIACE. Norton, M. (2004). Violence and Learning: Taking Action. Edmonton. Olivera, A. (1998). Peers and the Possibility of Change. Harm Reduction Communication http://www.harmreduction.org/. Piche, D., Gleeson, C., Pacey, K., Lowman, J., Childs, M., Ciarrocchi, S., et al. (2006).Beyond Decriminalization: Sex Work, Human Rights and a New Framework for Law Reform. Vancouver: Pivot Legal Society. Rekart, M. L. (2005). Sex-work harm reduction. Lancet, 366, 2123–2134. Riley, D., & O'Hare, P. (1999). Harm Reduction: History, Definition, and Practice. In J. A. Inciardi & L. D. Harrison (Eds.), Harm Reduction: National and International Perspectives (pp. 21). Thousand Oaks: Sage. Robertson, S., & Poole, N. (1999). Backgrounder on Harm Reduction. Vancouver: Women's Addiction Foundation. Ruefli, T., & Rogers, S. J. (2004). How do drug users define their progress in harmreduction programs? Qualitative research to develop user-generated outcomes. Harm Reduction Journal http://creativecommons.org/licenses/by/2.0, 1(8). Sochatsky, B., & Stewart, S. (undated). Changing paths. A literacy and lifeskills program for women in conflict with the law. Edmonton: Elizabeth Fry Society. St. Clair, R., & Chen, C.-Y. (2003). It Can't Help But Help: The Uses of Research in Adult Literacy Education. Paper presented at the Adult Education Research Conference. Stino, Z. H., & Palmer, B. C. (1999). Motivating women offenders through process-based writing in a literacy learning circle. Journal of Adolescent & Adult Literacy, 43(3), 282-291. Tatarsky, A. (1998). Harm Reduction Psychotherapy with Active Substance Users. Harm Reduction Communication http://www.harmreduction.org/, Spring 98. The Vancouver Agreement. (2000, September 27, 2007). The Vancouver Agreement. from http://www.vancouveragreement.ca/TheAgreement.htmTrumpener, B. (1997). Gimme Shelter! A Resource for Literacy and Homelessness Work. Retrieved May 20, 2006, 2006, fromhttp://www.nald.ca/library/learning/homeless/lithome.htmImprovements.. No Less than Heroic 66         ATTACHMENTSAttachment A: Focus group session outline Attachment B: List of Harm Reduction Strategies mentioned by research participants Attachment C: Suggestions from Research Participants re: the kinds of workshops and training experiences needed in the Downtown Eastside Attachment D: page from UpWords newsletter Improvements.. No Less than Heroic 67                  Attachment A: Focus group outline Introduction:  Welcome group and explain purpose of project: Capilano College and the  Lifeskills Centre are doing a research project to see if there are links between  learning and harm reduction. We would like your opinion on this.   Pass around consent letters and read through them as a group.   Questions:  1. Go round: What is one word or phrase you think of when you hear the words “harm reduction”? (list on flipchart) 2. Read the following “definition” together. What do you think of this definition? What would you add to it -- e.g. can you think of other risks to add to the list?  (list additions on flip-chart) Harm reduction is for people in our communities who do risky things. Some of these risks are: - using drugs - practicing unsafe sex - working in the sex trade - living with violence We accept, for better and for worse, that these activities are part of our world. We do not ask people to stop doing them, but try to help them be safer, take control and make changes only when they are ready. 3. What do you do to reduce harm in your life? 4. Have you participated in any learning activities (courses, workshops, school, college) recently? (list them on flipchart).  5. If yes to #4, did participation in these courses/workshops/classes help you to be safer and healthier?6. How can this learning centre help you to be safer and healthier? 7. Any other comments you want to make about learning and harm reduction. Also, feel free to write or draw pictures about this.  Improvements.. No Less than Heroic 68                                            Attachment B: List of Harm Reduction Strategies mentioned byresearch participants Drugs- do other things instead of drugs,  - use a mouthpiece, - I’ve yet to learn to say NO to share my pipe.  - I don’t buy from someone I don’t know.  - going to pick up clean and new materials - decreasing the occurrence and incident times (Focus Group written responses) - Find somewhere you can go to get away from the drugs  - safer using techniques  - instruction on using clean paraphernalia and equipment,  - needle to a pipe,  - Safe Injection Site, DAMS, NAOMI, VANDU - detox, recovery, referral, - doctoring (shooting you up safely),  - Naomi Project (North American Opiate Medication Initiative),  - cleaner dope, - don’t share needles - I try to keep drug and alcohol use to a minimum, not every day. The more you get, the more you want, the more you think you need Sex Trade - Safe Sex:  - I carry condoms with me all the time just in case.   - I do the best I can at refraining from turning to the sex trade  - I try not working the streets too often, and when I do I try to practice safe sex.  Sex Trade – Safety on the streets- I ask a lot of questions - I keep my eyes wide open. - I try to stay away from dangerous people. - I always have a spotter. - Have a buddy system - I try to stay away from dangerous people. - I always have a spotter. (Focus Group written responses) - Those pivot cards that tell you how to talk to a cop - Use a spotter - Have a buddy system Health- try to eat healthy - get enough sleep. - I participate in the Dr Peter Centre. This is a facility for HIV and AIDS.  - cleanliness and having the means to clean yourself, Improvements.. No Less than Heroic 69                              - good food, vitamins, clean water,- Hep C workshops, - being aware of health, - having an experienced, certifiable care-giver.  Relationships- Stay away from unhealthy relationships, men or women.  - I try not to bring much stress into my life or try not to analyze much of the stressful things that transpire in my daily life or with my current boyfriend.  Cooperation  - Sometimes other women do not have any and ask for them.   - I try to help those who ask.  Other- better education of the law, - Organizations: WISH, Health Contact Centre, InSite/ Safe Injection Site - Keep busy - When I’m going out to work I think about looking for flowers and not just about how I need money and drugs. - Stick to your moral values - I keep my own personal agenda - Join a program - Do Volunteer work - Get a job and get a life! - Slow down when you do something, take a break  - Have a positive interaction in the community,  do volunteer work, volunteer on a board Improvements.. No Less than Heroic 70                              Attachment C: Suggestions from Research Participants re: the kinds of workshops and training experiences needed in the Downtown Eastside Courses and workshops on: - living with violence and self defence - Coping skills – psychological ways of dealing with men as a means to avoid conflict If a guy is trying to be aggressive with you, and you play with him and say “oh baby”, maybe he’ll back the truck up and stop.  - a classroom, - 2-3 hours on safe sex - info sessions on education and housing - computer skills   - upgrading classes - More workshops and schooling - More information sessions and workshopsWays to promote the work of the WISH Learning Centre:- More notices out in the other area about what is going on - A calendar with a weekly agenda being posted, or a board with “What is going on” similar to LifeSkills. Suggestions for UpWords Group: - A Website: This group could write awesome essays and articles on everyday life. e.g. how a Latino lives in the DTES – without being labelled as a drug dealer. If we get a website up, more of these stories can be told. - It would be a good goal to work towards one issue and find common ground.  - Keep the group going!  General:  You can provide information on other programs,  the PEERs program was mentioned by  Karen and how much it helped her (she found out about it at WISH).Sugar Mama needs computer access because she wants to train to be a corrections officer. Someone else mentioned a life coach.  Improvements.. No Less than Heroic 71      Attachment D: A page from the UpWords newsletterImprovements.. No Less than Heroic 72          Welcome to UpWordsWelcome readers to the very first issue of UpWords. This quarterly publication is written, edited, and produced by members of the LifeSkills Centre and residents of the Downtown Eastside. UpWords is a voice for those who have few places to tell their stories and share their real challenges of living with a drug addiction and writing about the culture that surrounds it. We want to bring our expertise in Harm Reduction to a broader audience, while talking about the risks involved in being exposed to a street level drug trade, within a tightly knit communitythat holds closely as many uplifting tales as it does tragedies. Several months ago at The LifeSkills Centre what used to be called the Stimulant User Support Group started meeting, brainstorming, and eating together on a weekly basis. We envisioned a publication that was inclusive, community based, and one that could be used as a tool to bring humanity to a demonized population, while breaking down some walls between those using Crack and Methamphetamine and the greater community. thus was born... Up Words. This incredible group of dedicated members became writers, editors, photographers and cartoonists. Collectively this monumental 1st edition has been produced. As I write our first editorial, I am already excited about the submissions for our next edition. We really hope you enjoy this little paper, and look forward to your comments and suggestions (some of which may be published if you like!). All of us at UpWords would like to thank Murray Bush for his patience, leadership and fantastic layout! We would like to dedicate this premiere edition to our fallen friend, Rick Morrison. You are greatly missed - RIP. Until the New Year...  - COCOPUNITIVE NEW CRYSTAL METH LAW MISSES 'POINT' I have to agree with Mark Townsend of the Portland that new stricter sentencing alone cannot fix the rising crystal meth epidemic. It is totally obvious that there is a huge drug problem here in the Downtown Eastside and the harder the police try to stop the dealers, the smarter they[the dealers] are. A lot of Crystal Meth addicts use it because it is cheap and easy to get, but most of all for pain relief. Pain, includes the effects of emotional and physical abuse, as the result of growing up in a dysfunctional home or family. Many addicts were not given a choice, as they were subjected to it at an early age and need it to function normally. I find the new law to be far too extreme a form of punishment for those who are still in their adolescent years. Would you like to end up in jail for life over a shard that doesn't even weigh an actual point [tenth of a gram]? Please think about it!  - LISA OLM (McGARTHY)

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