Understanding Harm Reduction: From Set and Setting to Policy
This year millions of people will take psychedelics. For many, this will produce entirely positive and potentially life changing experiences. For some, however, the experience will be challenging.
The term “harm reduction” refers to attempts to minimize any negative outcomes that might be possible once one has consumed a substance. It consists of a set of principles, ideas and strategies that people can employ in order to have safer experiences of altered states. These efforts as a whole are based on the idea that people will always consume mind-altering substances and so, rather than deterring people from using any substance or ignoring this behaviour, we can instead promote safe, responsible use. When LSD burst onto the scene in the 1960s, it was legal to buy from pharmacies. This meant that it was free from any form of government regulation, leaving the responsibility for reducing harm to the psychedelic community itself. As news of the powerful effects of LSD leaked out from the research institutions where it was being studied into the wider culture, it was Timothy Leary who provided the community with its most enduring harm reduction concept: set and setting. By the late 60s, LSD consumption had been criminalized in order to suppress the anti-Vietnam war counterculture that had emerged [1] and this criminalization was justified through the logic of harm reduction. A moral panic was created that led to false stories appearing in papers (such as the classic: “Girl gives birth to a frog: Doctors blame LSD”) [2] and the wide publication of junk science [3]. The mainstream public tolerated prohibition because they thought it was keeping people safe. In the US, criminalization has not been successful at eliminating drug consumption. In 2016, a report from the American Civil Liberties Union (ACLU) found that every 25 seconds someone is arrested for possessing an illegal substance for personal use [4]. Pushing this activity underground actually increases the possibility of harm, as drugs on the black market can be adulterated with other dangerous substances, and as the fear of prosecution can deter people from seeking assistance when they need it—not to mention the psychological and physical harm that can come from arrest and criminal punishment. In the midst of this lack of effective harm reduction from the government, it was the psychedelic community itself that again took up the challenge of reducing harm. In the mid-to-late 90s, nonprofits dedicated to harm reduction and drug education began to emerge. The websites Erowid and Dance Safe were founded at this time with the intention of providing educational resources to those who were considering taking a substance. Dance Safe also facilitates drug checking by offering testing kits on their website that can be used in order to test the chemical content of any substance. In 2003, then-senator Joe Biden sponsored the Reducing Americans’ Vulnerability to Ecstasy (RAVE) Act in the US Senate. The act made it possible to prosecute bar and club owners if drugs were consumed in their establishment; punishable with a fine of up to a quarter million dollars or 20 years in prison. This act introduced guidance for law enforcement on how to go about targeting institutions where drugs might be being consumed. Is a club providing free water and a space for people to cool down so they don’t overheat? Such a club would now be considered suspicious in the eyes of the law. This resulted in club owners being disincentivized from actively supporting the safety of their clientele. Providing medical help of any kind could be construed as profiting from a business model based on the use of drugs, leaving the business owners legally responsible. Such laws increase the challenge of reducing harm amongst those who recreationally use drugs in public venues. One public “venue” in particular looms large when imagining places where drugs are consumed in the US: Burning Man. This nine-day art, music, and community-oriented gathering of approximately 70,000 people, held every year in the Nevada desert, was the birthplace of one of the most prominent contemporary harm reduction organizations, the Zendo Project. In 2012, Zendo set up a space for people undergoing difficult psychedelic experiences at Burning Man. Since then, they have provided support at many other festivals. The volunteers at the Zendo sit with people who require their services for the duration of their trip, talking them through it and helping them to surrender to the experience and feel safe. Helping to calm someone’s mindset and offering a safe setting is not only a good idea before a psychedelic experience, but even in the midst of a difficult experience. Psychedelics do not have a single, specific, repeatable effect – the effects are highly influenced by context, both internal and external. The “set” in “set and setting” refers to the mindset of the person who is considering undergoing a psychedelic experience—their internal context. One’s mood, stress levels and expectations around what the experience will be like can all influence the course of the trip. If you feel safe and relaxed and you know why you’re about to undergo the experience, you’ve increased your chances of having a very positive experience. If you feel unsafe and throw yourself into the experience without much thought, there’s a greater chance your experience might be one of overwhelming disorientation and fear. This brings us to the “setting”—their external context. Set and setting are intimately linked; whether you are around people you trust or alone in a safe and supportive setting, your mindset is more likely to be in the right place to undergo the experience. A physically or socially unsafe or unpredictable setting is likely to push your mindset in a more fearful direction. Having a sober friend or a guide sit with you for the duration of your experience can be another highly effective form of harm reduction. Not only can a well-selected trip-sitter be a source of reassurance if one feels fearful during the trip, they can also look out for the physical safety of the individual undergoing the experience. If no one ever took drugs, there would be no harm caused by drugs. This logic is often used to justify the illegality of drugs, but in reality, the threat of punishment doesn’t scare people into total abstinence and actually increases the risk of potential harm by pushing drug use underground. Certain laws do exist, however, that truly support harm reduction.
The 911 Good Samaritan Law is a prime example of this. If you were consuming an illicit substance with someone else who got into some kind of trouble where you might need to call the police, you would be faced with the issue that you might get arrested for drug possession. In order to avoid people being scared to call the cops when necessary to help someone, the 911 Good Samaritan Law makes a provision that the person reporting the issue cannot be prosecuted for drug possession. All 50 states and Washington DC have Good Samaritan laws of some kind but the details vary by state [5]. When four decades of authoritarian rule came to an end in 1974 with the Carnation Revolution, Portugal opened up to the world. Over the coming years, heroin and marijuana started to flow through the port towns of the south coast. By 1999, opiate addiction was widespread and Portugal had the highest rate of HIV amongst those who injected drugs in the entire European Union. In 2001, Portugal took a seemingly radical step to deal with their drug issue: they decriminalized all drugs. Individuals could no longer be arrested for possession and consumption of a personal supply of any substance. Decriminalization is not the same as legalization however. Individuals who were caught with a substance that was not legal might be given a warning, a fine, asked to perform community service or directed towards harm reduction services or treatment facilities. Each case is decided by a commission of legal professionals, medical professionals and social workers although, in the majority of cases, the individual is given no penalty. Decriminalization made it possible for a wide range of harm reduction efforts to be rolled out, from needle exchange programs, so that people could access clean needles in order to reduce the spread of HIV and other blood-borne diseases, to substitution treatment with substances such as methadone. In the 11 years following decriminalization, the rate of HIV diagnoses among those who inject drugs dropped from 1,016 in 2001 to 56 in 2012, and new cases of AIDS fell from 568 to 38 [6]. Boom Festival, a biennial psytrance music festival held in Portugal and mainstay of the European psychedelic scene, has been at the forefront of psychedelic harm reduction in Europe since 2002. This has been possible as a result of Protuguese decriminalization. Kosmicare, Boom’s harm reduction program, provides drug testing areas, seating areas, and public alerts when they are needed. It is staffed by therapists, psychologists and volunteers and works in collaboration with the festival’s medical services as well as health services outside the festival in the region. Decriminalization has made it possible for festival-goers to know the exact chemical composition and strength of the substances they are considering taking, which also allows them to more accurately consider their dosages, reducing the chances of unintentional over-consumption. After taking the substance, they have access to medical provisions should things go wrong, without fear of the harms that come with arrest and the associated criminal punishment. Harm reduction begins with education. In the age of the internet, it’s never been easier to stay informed about substances that you might intend to consume. Information is now widely available on the likely effects of any substance by dose. For example, Reality Sandwich provides both Substance Guides and Dosage Guides to help educate readers on various substances. Beyond this, you can be even more informed by purchasing testing kits to test the chemical composition of the substance. Educating yourself on what provisions for support might be available to you, whether it’s Good Samaritan laws or chill-out spaces at festivals, can only help you to stay safer. None of this is a replacement for giving serious consideration to one’s set and setting however. Once you’ve taken the necessary steps to ensure you’re likely to have an amazing experience, there’s nothing left but to follow Leary’s other enduring piece of advice: “turn off your mind, relax and float downstream”. Dr. James Cooke is a neuroscientist, writer, and speaker, whose work focuses on consciousness, with a particular interest in meditative and psychedelic states. He studied Experimental Psychology and Neuroscience at Oxford University and is passionate about exploring the relationship between science and spirituality, which he does via his writing and his YouTube channel, YouTube.com/DrJamesCooke. He splits his time between London and the mountains of Portugal where he is building a retreat centre, The Surrender Homestead, @TheSurrenderHomestead on Instagram. Find him @DrJamesCooke on Instagram, Twitter and Facebook, or at DrJamesCooke.com. [1] https://edition.cnn.com/2016/03/23/politics/john-ehrlichman-richard-nixon-drug-war-blacks-hippie/index.html [2] https://dangerousminds.net/comments/girl_gives_birth_to_frog_lsd_to_blame [3] https://pubmed.ncbi.nlm.nih.gov/4994465/ [4] https://www.aclu.org/report/every-25-seconds-human-toll-criminalizing-drug-use-united-states [5] https://recreation-law.com/2014/05/28/good-samaritan-laws-by-state/ [6] European Monitoring Centre for Drugs and Drug Addiction (2014) ‘Data and statistics’. https://transformdrugs.org/drug-decriminalisation-in-portugal-setting-the-record-straight/.
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