When we talk about “treatment,” whether it’s in the context of a loved one’s addiction or addressing homelessness, we’re usually referring to traditional 28-day rehab—the “solution” of choice for insurance companies, policymakers, and desperate people looking for help. The problem is, 28-day treatment is one of the least effective methods to get people sober, leading to cycles of treatment and relapse that can cost patients hundreds of thousands of dollars without results.
I recently wrote an in-depth story about the growing consensus that 28-day rehab is the wrong approach. Check out the intro, then read the full story at HuffPost.
When Jessye first “graduated” from a 28-day treatment center outside Seattle, she knew she wouldn’t be able to stay clean. She became addicted to pain medication while dealing with endometriosis, and by the time she showed up at the doors of the private, for-profit rehab, she had been using Percocet for four years.
“When that got too expensive, I turned to heroin,” said the 34-year-old, who asked us not to use her last name out of concern that it might harm her professionally.
Fresh out of rehab, she was jobless, homeless and sleeping in her car, which was owned by an aunt. Then her family took away the car, because they didn’t want to enable her. After a couple of weeks, she started using again.
“I was really afraid,” said Jessye. “I really wanted to stay clean, and I really tried, but ultimately, they didn’t set me up for success.”
Addiction treatment is a big business. More than 2 million Americans spend a total of $28 billion every year on treatment at nearly 15,000 facilities across the country, according to the National Survey on Drug Abuse. About 12 percent of those opt for four-week treatment, which can cost anywhere from $10,000 to more than $30,000 a month. Many clients return multiple times before it sticks.
According to the Substance Abuse and Mental Health Services Administration, two-thirds of people who go to treatment end up going back at least once, with 20 percent entering treatment five times or more. The money flowing through private treatment companies creates perverse incentives for treatment centers ― if treatment failed, patients and their families are told, it’s probably because the patient failed at treatment.
Advocates for harm reduction took strong exception to a set of recommendations from a joint city-county “High Barrier Individuals Working Group”, arguing that several of the proposals are just extensions of the existing, punishment-based criminal justice system rather than the kind of programs that make meaningful, lasting change in the lives of people suffering from severe addiction and mental illness.
The four-pronged plan, which Mayor Jenny Durkan, King County Executive Dow Constantine, City Attorney Pete Holmes, and King County Prosecutor Dan Satterberg announced last week, came out of the recommendations of a work group assembled to respond to former city attorney candidate Scott Lindsay’s controversial “System Failure” report last year. That report looked at the records of 100 people with long lists of misdemeanor charges and determined that many of them had failed to comply with conditions imposed by the court, such as mandatory abstinence-based treatment, random drug and alcohol tests, and appearing regularly in court.
“We have too many people who’ve been cycling through the criminal justice system and we have not been able to design the right interventions for that,” Durkan said in announcing the proposals last week. “We had some of the highest-cost interventions that were also the least effective. We knew we needed to come together and bring people across jurisdictions to address this issue.” Satterberg described the proposal’s goals more bluntly: City and county officials needed a way “to manage what we see as obvious social disorder.”
The four pillars of the plan, which would be partly funded through Durkan’s upcoming budget proposal, are:
• Expanded probation. This would include a new “high-barrier caseload” model, in which probation officers (described in the recommendations as “probation counselors”) would meet with parolees outside the probation office and parolees would be required to show up in court more frequently; and a “high-barrier treatment” model, in which offenders would get reduced sentences in exchange for going to inpatient addiction treatment.
According to Durkan, “probation counselors” with “special training in harm reduction…will meet with individuals where they are in the field, have more frequent review hearings with judges, and give people that chance to spend less time in jail only if they agree to certain dependency treatment.”
Harm reduction advocates say adding more obstacles, such as additional mandatory court dates and coercive treatment, represents a fundamental misunderstanding of the concept, which relies on non-coercive tactics to help people achieve better health, fewer arrests, and a better quality of life. This, in turn, reduces the harm they cause the community. They also argue that sending probation officers out into the field to track down clients and provide “counseling” will cause confusion and could lead to greater harm to people on probation, because probation officers (unlike real counselors) are obligated to tell the judge if a client is violating the terms of their probation.
“It would be incongruous and disingenuous to train probation officers in harm reduction counseling if the judges—to whom the probation officers report—were to use coercion to force people into mandated and abstinence-based treatment and require abstinence in return for reduced sentencing.”
“I’ve found in my clinical practice that clients start to get confused when parole officers start calling themselves ‘probation counselors’ because they start to think, ‘I can tell this person anything, and, I can tell them how I’m really doing,’ but [the probation officers] are still in this adversarial role,” says Susan Collins, co-director of the Harm Reduction Research and Treatment (HaRRT) Center at the University of Washington.For example, if someone on probation told their “probation counselor” that he was struggling to abstain from drugs and alcohol, the officer would have to report that to a judge as a probation violation, which could land the parolee back in jail.
Mandatory treatment is also contrary to harm reduction, because it makes sobriety, rather than improved outcomes, the goal. “Harm reduction doesn’t have to be at odds with serving protecting public safety. In fact, these goals would seem to be very compatible if we weren’t so fixated on abstinence achievement as a proxy for not committing crimes.” Moreover, it isn’t very effective, especially for people with severe drug and alcohol use disorders who are also facing other major challenges such as a criminal record and homelessness.
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The “success” rate of short-term inpatient treatment, which is what the report recommends for parolees struggling with substance use disorders, is abysmally low already (about 9 out of 10 people with alcohol disorders who enter inpatient treatment, for example, relapse in the first four years), and the “success” rate for people with no support system or place to live when they get out is likely even lower. Although the work group’s report quotes an NIH pamphlet saying that “treatment does not have to be voluntary to be effective,” that pamphlet does not include links to actual research, which shows that although forced treatment can work, it usually doesn’t. The most recent research on the kind of severely addicted, chronically homeless people the probation proposal is supposed to address, Collins points out, actually showed that mandatory 28-day inpatient treatment was the least effective form of treatment.
“In addition to the nonexistent research foundation for coerced or mandated abstinence-based treatment for this population, the proposed approach is troubling philosophically,” Collins says. “It would be incongruous and disingenuous to train probation officers in harm reduction counseling if the judges—to whom the probation officers report—were to use coercion to force people into mandated and abstinence-based treatment and require abstinence in return for reduced sentencing. This is like a bait-and-switch for some of the most vulnerable folks in our community.”
Harm reduction advocates say adding more obstacles, such as additional mandatory court dates and coercive treatment, represents a fundamental misunderstanding of the concept, which relies on non-coercive tactics to help people achieve better health, fewer arrests, and a better quality of life.
Holmes, speaking last week, said expanded probation, with enforcement mechanisms like “random UAs [drug tests]” and consequences for noncompliance, would be complementary to LEAD’s “softer touch.” “We’re talking about a challenging population that does need the specter of a court intervention or revocation hearing [that] can follow when someone doesn’t comply with the terms of their probation. … We do have to [consider] public safety first, and a probation officer is going to be able to bring noncompliance to our attention so that probation can be revoked and sentencing reimposed as necessary.”
Collins, with the HaRRT Center, says “harm reduction”—like the Downtown Emergency Service Center’s successful program for people with alcohol use disorders at 1811 Eastlake— “doesn’t have to be at odds with serving protecting public safety. In fact, these goals would seem to be very compatible if we weren’t so fixated on abstinence achievement as a proxy for not committing crimes.”
• The expansion of a recently opened shelter in the decommissioned west wing of the King County jail by 60 beds, which Durkan suggested could be reserved for “high-barrier offenders.” Durkan claimed last week that the shelter would be a “comprehensive place-based treatment center” with “on-site treatment for mental health and substance abuse disorders… something that doesn’t exist” yet in the city.
This statement—repeated by the Seattle Times, which described the shelter as a “60-bed treatment center”—is inaccurate.
“It’s going to be a shelter,” says DESC director Daniel Malone. “So, just to be really clear—it’s not going to be licensed as a treatment facility, but we will bring behavioral health treatment resources there. … What we do in a lot of our locations is have a regular, often scheduled, presence of different kinds of behavioral health specialists there to engage with people, form relationships, and help them access services.” (City officials were apparently asked to stop referring to the shelter as a treatment center prior to Durkan’s remarks last week.)Continue reading “New Plan for Dealing With “Prolific Offenders” Substitutes Punishment for Harm Reduction, Advocates Say”→
This post originally appeared on Seattle magazine’s website.
Last Friday marked the long-awaited, and final, meeting of the One Table regional task force on homelessness—a group of political, nonprofit, business, and philanthropic leaders formed last year to come up with an action plan to address the root causes of homelessness in King County.
Did they do it? Not exactly. One Table’s final work product—a list of recommendations and general timelines (“within one year,” “in 3-10 years,” etc.) with no dollar figures or chains of responsibility for implementation—hasn’t changed substantially since April, when the group last met to discuss a set of “recommended actions.” Those actions include things like funding long-term rental subsidies, expanding opportunities for behavioral health jobs for people of color, creating training programs for high-wage jobs aimed at vulnerable communities, and expediting permits for affordable housing.
With that in mind, here are five key takeaways from the eight-month One Table process.
1. Nothing to see here.
Several media relations folks mentioned to me that they didn’t really publicize the final One Table meeting because, frankly, there wasn’t much news, and that was evident from the opening remarks by King County Executive Dow Constantine and Seattle Mayor Jenny Durkan. Constantine touted the fact that he was moving up the timeline for issuing $100 million in housing bonds that will be paid back by future proceeds from the county’s hotel/motel tax, which will make the money available slightly earlier but does not represent new funding. (Those funds can only be used for “workforce housing” near transit stops, so it won’t directly impact people living unsheltered or in deep poverty anyway). And Durkan, whose “deal” with Amazon on an employee hours tax that would have brought in $75 million a year for housing and shelter fell through almost instantly, touted her innovation advisory council—a group of tech companies that will advise the city on homelessness, but have not committed any funding to implement whatever “solutions” they come up with—as well as several upcoming Pearl Jam charity concerts and the potential for building modular housing. None of this was news, and it set the stage for a two-hour meeting where basically nothing was announced.
One Table members broke up into small groups—that is, many small tables—to discuss “root cause” areas including affordable housing, behavioral health, criminal justice, child welfare, and employment. They had half an hour to come up with a list of “solutions.” I sat in on a table that included Plymouth Housing director Paul Lambros, Seattle Housing Authority director Andrew Lofton, and Chief Seattle Club director Colleen Echohawk. Their primary recommendations? “Build and maintain more affordable housing.” This, they said, could include increasing the federal low-income housing tax credit (not likely given the current Administration’s mission of dismantling HUD and federal programs that benefit the poor), providing incentives for banks to fund construction and ongoing maintenance of low-income apartments; and making it clear to the public that, as Gates Foundation program officer Kollin Min put it, “there’s a direct correlation between the lack of housing and homelessness.”
Other groups came back with the same conclusion: Preventing homelessness and preserving existing affordable housing were important, but the region just needs more funding for housing. A similar conclusion emerged out of the groups focused on behavioral health: Without money for mental health care and substance abuse treatment, and funds to build housing for people when they get out of treatment so they don’t end up right back where they were, addressing “root causes” will be impossible. “Ultimately, the need is housing and money,” a report back from one of the behavioral health tables concluded.
3. Tribalism over regionalism.
It’s pretty clear that for all the lofty talk of “regional solutions,” the leaders of the One Table task force remain starkly divided over what will constitute the right solutions for different parts of the county and who’s to blame. Auburn Mayor Nancy Backus reiterated the points she and the leaders of four other suburban cities made in a letter urging her fellow One Table leaders to support a plan to force homeless people “who refuse treatment” into forced lockdown detox using a state law designed to allow family members to intervene on behalf of people who pose an imminent threat to themselves. “We know these individuals. We might see them on a regular basis. They’re familiar individuals and they’re not willing to accept help. At some point in time, we need to be able to say, you are going to get help,” Backus said. And she touted a church-run food bank in her cities that requires people who are capable of working to “pick up a rag and soap” or clean up garbage as a condition of receiving food.
“The cities outside of Seattle have different needs,” Backus said. “What works for Auburn, what works for Bellevue, isn’t going to work for the city of Seattle, and we have to realize that.” That is pretty much the opposite of a “regional” approach, and is unlikely to fly with the leaders of bigger governments like King County and Seattle who tend to balk at ideas like forced treatment and unpaid labor.
What will become of One Table’s recommendations remains unclear. Rachel Smith, Constantine’s chief of staff, told the group that the county has hired consultant Marc Dones with the Center for Social Innovation to “guide our work with expertise” as the county comes up with an implementation plan for the recommendations. For now, One Table’s work is concluded—and an action plan to address the root causes of homelessness remains unfinished.
Last month, Seattle Times columnist Danny Westneat wrote a column that struck a chord with many Seattle residents, particularly those already inclined to believe that people choose to be homeless and addicted to drugs or alcohol. It struck a chord with me, too, although not for the same (or probably the intended) reasons. In the column, Westneat marveled that just a few blocks from the Jungle—the dangerous, massive, unpoliced encampment that stretches along the west side of Beacon Hill—there is a “shelter” that has empty beds every night. (The “shelter” is not actually a shelter, but a long-term Christian rehabilitation center run by the Salvation Army).
“Some shelter beds go empty—even right next to Seattle’s Jungle encampment,” Westneat’s headline roared. “How can this be?,” Westneat wondered. “How can a homeless rehab center next to the city’s most notorious encampment have 10 to 30 empty beds?” Why would anyone in their right mind turn down a “free 60-day stay” in a warm place with food and running water for the dangerous, cold, risky life on offer in a no-man’s land like the Jungle?
This story is an attempt to explain part of how that can be, starting with the difficulties homeless people face on the path toward treatment for drug and alcohol addiction, and ending with the overburdened shelter system itself, including the Salvation Army rehab center. The questions behind the surface Westneat scratches—with more than 400 homeless people living around a freeway overpass nearby, how on earth could these beds be empty?—are deeper and more difficult to answer than such glib incredulity implies. They include: Who “deserves” government-funded services? Why do some people decline services, including treatment? And what obligation do we have to people who can’t or won’t get help but still, because they are people, need a place to lay their heads?
“We’ve got hundreds of beds in the city every night that people don’t want to go to,” Magnolia homeowner George Pierce said at a meeting of the Magnolia Community Council last week. “How do you get these people out from under the Magnolia Bridge who are stealing, leaving human waste, leaving terrible conditions that city officials have done nothing about?”
Those who do outreach to the homeless and work to get them shelter tell a different story. Chloe Gale, co-director of the REACH program at Evergreen Treatment Services, does direct street outreach to encampments. She says that “in general, all of the beds in our shelter system in the city are full all the time.” Although the city opened up 300 new shelter beds as part of the recent emergency declaration on homelessness, Gale says those beds “filled within days, and most shelters end up turning people away” night after night. While some people living in tents or sleeping on bedrolls under freeways are there because they want to be there or can’t go to regular shelters (which generally bar couples, pets, and people who aren’t sober), “I know there are people who really want shelter and are lined up every night and are getting turned away,” Gale says.
Pierce’s wife, Cindy Pierce, is the head of the Neighborhood Safety Alliance, a group made up of homeowners in Magnolia, Queen Anne, and Ballard who oppose the presence of illegal encampments in their neighborhoods. Like many, Pierce draws a bright line between the “deserving” or “truly” homeless who are mentally ill or just down on their luck and those who “choose” to be homeless or continue to depend on drugs and alcohol. “There is a huge difference,” she insisted at a roundtable “Civic Cocktail” discussion hosted by CityClub and Crosscut earlier this month.. “There’s the mental[ly ill], which, we as a society must take care of these people and we must house these people, and the illegal campers out there.”
Despite the views expressed Pierce and many other camp opponents in neighborhoods like Magnolia, the road to treatment and recovery isn’t typically a straight line from a place like the Jungle to a new life as a sober, employable, stably housed member of society. Willpower alone won’t get an addict sober (nor will throwing an addict in jail for a few days), and even addicts who want help end up on long waiting lists for initial intake into treatment programs; by the time their number is up, the window in which they are desperate enough or willing enough or just done enough to want help may have closed.
For many addicts, homeless or not, the first step toward treatment and recovery is detoxification—getting the drug or alcohol out of a person’s system. For alcohol abusers, in particular, detox can be critical: Although many drugs have withdrawal periods that are just more physically unpleasant, only alcohol withdrawal has a relatively high chance of causing a potentially fatal seizure or heart attack, which is why medically supervised detox, with the help of drugs that ease the withdrawal process, is often necessary for chronic drinkers.
But detox beds are in short supply, with wait lists that can stretch weeks or months. If you’re ready change your life starting today, good luck getting into detox even if you do have money; without it, your options are limited to a few behavioral health centers that contract with the county to provide about three dozen beds for low-income patients at facilities in South Park, Kirkland, and Burien. Those 36 beds are the only non-hospital detox beds for Medicaid patients in King County.
King County Health’s behavioral health and recovery division director Brad Finegood says the county knows the beds they have aren’t enough to serve the county at a time when heroin addiction is on the rise and the population is growing. “We are definitely working as hard as we can to build long-term detox capacity,” Finegood says. “We know we need to be able to provide treatment on demand and, when people need treatment, to provide open access.” But they aren’t there yet.
There was another facility in Seattle, run by Recovery Centers of King County—a nonprofit services provider that suddenly closed its doors last year under the shadow of a federal probe and allegations of unpaid wages. The closure of RCKC, which provided 27 beds for low-income addicts, went unmentioned in the local media except by Seattle Weekly, which broke the news of the closure.
But homeless advocates noticed. Gale, of Evergreen Treatment Centers, says RCKC, which offered bare-bones detox and residential treatment out of a modest building on First Hill, was “a critical treatment facility for people that were homeless. It was the main medical detox program for people getting Medicaid funding, and a significant percentage of the population [there] was homeless or formerly homeless. It’s not perfect, but it did its job, and it’s been there for decades.” And now it’s gone.
Finegood says Medicaid rules dictate that detox facilities can’t have more than 16 beds—an unintended consequence of rules designed to prevent the warehousing of mental-health patients—although he says that rule is set to expire in April. Another 20 or 30 beds are coming online at two other facilities later this year, Finegood says—alleviating the problem but hardly serving the needs of an entire, growing county.
And detox, Finegood says, is often the first stop before actual, long-term treatment, either residential or outpatient. “We definitely know and understand that detox is a really key component of getting people into treatment in a number of different ways,” Finegood says. “We engage people into a number of different treatment services.” Treatment, as opposed to detox, is where the long work of recovery often begins, and the process of reacclimating a person who may have been living on the streets, hustling for drugs and barely scraping by, for yours, into straight society.
Timothy Rockey, head of the Salvation Army Adult Rehabilitation Center with which Westneat was so enamored, says that for many, the first barrier to entering the ARC program is that new residents must arrive with a few days’ sobriety under the belts—the ARC doesn’t provide detox. And there are other barriers to entry for programs like the Salvation Army’s, which I’ll describe in more detail in Part 2, which will focus on the advantages and disadvantages of high-barrier and low-barrier approaches to shelter and addiction treatment, later this week.