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?

On Monday, I reported on some of the barriers homeless people who are addicted to drugs face to getting “in the system” of treatment and recovery. (In that piece, I used the term “addict,” which is common in treatment and recovery programs but which some in the homeless advocacy community prefer to avoid because it can be “othering” and reinforce the stigma around drug addiction. When appropriate, I will use the terms “drug and alcohol abusers” and “drug and alcohol dependency,” but I feel the terms addict and addiction are useful because they acknowledge explicitly that drug dependency is a disease, not a lifestyle choice. )

Today, I’ll report on two different approaches to helping homeless people recover from addiction and get into shelter and more permanent housing. The first, espoused by the Salvation Army and presented by Westneat as a no-brainer option for all addicted people experiencing homelessness, is what I’ll call the “high-barrier” approach–requiring clients to commit up front to certain behaviors, including sobriety, and a program of recovery that may include church attendance, Bible study, and unpaid work. The second is the “low-barrier” approach; this model includes shelter and housing for people who are actively using drugs or alcohol as well as related harm-reduction programs such as  safe injection sites. High-barrier entry points are controversial because they exclude people who are unable or unwilling to meet the requirements, and privilege those who are ready or desperate enough to totally overhaul their lives; low-barrier services are controversial because they allow people to continue behavior that is illegal or that some wish to eradicate, like abusing drugs and alcohol and related nuisance crimes.

In his column, Westneat glorified the high-barrier approach while conveniently glossing over the height of that barrier. The closest he came was a breezy, “Now some of this may be because the Salvation Army has rules you have to follow”–as if “rules” like sobriety, a schedule that is dictated for you minute by minute, and mandatory work are simple bumps in the road to a normal, healthy, productive existence.

Part of the problem with thinking this way is that it fails to acknowledge the reasons people “choose” to be addicted to drugs and living on the streets. When your underlying thesis is that people who won’t enter a program are just stubborn or don’t want help, it’s easy to ignore the fact that the help the Salvation Army offers at its Adult Rehabilitation Centers is a six-month residential program that requires Bible study, church attendance, and the willingness to work a full-time job for no pay beyond room, board, and a small stipend for incidentals from the Salvation Army commissary.

Timothy Rockey, the compact, intense Southerner who runs Seattle’s Adult Rehabilitation Center,  strongly believes that people who want to recover need to take personal responsibility for their actions, and he dismisses many aspects of harm reduction—like providing trash and sewer service in the Jungle–as destructive. “My idea of enabling is something that prevents someone from being able to make choices. I believe God gave us free will, and anything that violate’s someone’s free will is enabling,” Rockey says.

“Simply because something’s a disease doesn’t mean we don’t have to be accountable for how we deal with the disease,” he continues. “Whether it was triggered by trauma or because of life choices, it should be treated the same way.” Rockey likens the disease of addiction to diabetes—even though it’s not your fault, you have to take insulin every day, eat right, and “have discipline” to keep it under control.

At the ARC, that discipline takes the form of a rigid daily schedule that begins before sunrise with a shower, breakfast, and a “brief devotional” at 6:30, followed by a full work day in the residence itself, the office, or a Salvation Army warehouse. After dinner, which has a dress code, the residents go to Bible study or 12-step meetings. The goal of all this regimentation, Rockey says, is to retrain people used to the chaos of the streets to function in a society that has schedules and rules.

The program is explicitly Christian. As the center’s website notes, “Each program participant is provided with a clean and healthy living environment, good food, work therapy, leisure time activities, group and individual counseling, spiritual direction, and resources to develop life skills and a personal relationship with God as provided by Jesus Christ.”

“Yeah, we’re a church,” Rockey says of the Salvation Army and its private rehab center. “The Supreme Court says we can discriminate on that. It’s fine if you’re not religious, but you are required to participate. I was an atheist for many years but I went to weddings in churches, I went to funerals in churches, and it didn’t hurt me to be exposed to other religions.”

But, Gale points out, the faith-based nature of the program does alienate many who have had negative experiences with organized religion, or who simply don’t adhere to the Christian principles on which the Salvation Army program hangs. “That Christian-based model doesn’t work for everybody,” Gale says, describing a REACH client who felt unable to participate in his own Native American spiritual practices at the ARC and dropped out of the program. “In the native community, there are people who may have been Alaska natives with experiences in orphanages who may not feel comfortable participating in a system that is run by a Christian organization,” she says.

Moreover, Gale points out, the Salvation Army doesn’t offer medical detox, because it isn’t a medical facility; as I reported Monday, there are only about three dozen detox beds to serve all the low-income addicts in King County, and detox is often critically necessary to keep people from dying during severe withdrawal.

Mark Putnam, head of All Home, the King County organization dedicated to reducing homelessness and making it “brief, one-time, and rare” (in its previous incarnation, All Home was known as the King County Committee to End Homelessness), says treatment centers like the Salvation Army represent “the complete opposite of best practice” for getting people off drugs or alcohol and off the streets, because they apply a one-size-fits-all approach to a very diverse population of potential clients.

“It’s the opposite of a client-centered approach, which asks, what does the client need?” Putnam says. “Sure, there’s a whole segment of our county and society that says, ‘screw what they want and what their preferences are—if they don’t like what we’re giving them, let’s put them in jail.’ But that’s not how you make progress on homelessness. Actually, you need to lower the bar—first get people into housing, then address all the other issues. When you have a program like that that isn’t full, that should tell you they’re doing something wrong.” The model Putnam is describing is called Housing First, and is based on the notion that giving people experiencing homelessness a roof over their heads makes solving root-cause problems like addiction much easier than trying to do it the other way around.

Brad Finegood, director of King County Public Health’s behavioral health and recovery division, says that in the absence of a comprehensive, funded plan to house the  county’s homeless population, the best way to get homeless people who are addicted to drugs or alcohol into treatment is to meet them where they are, and sometimes, that means places like the Jungle. King County sends outreach teams like REACH out into the many homeless encampments around the city, to do welfare checks, see what people need and if they’re relatively safe, and whether they need medical attention.

“If I’m a provider and I go out to the Jungle and I say, ‘We want you go come to our treatment agency,’ and they thumb their nose at that, it can’t be an all or nothing thing. We have to be able to say, ‘Cool, you’re not ready for it—what about this type of service? Can I get you some medical help while while you’re out  here? We have to try to start engaging people where they’re at and, when they’re ready to  come out of the cold, to have those resources  available.”

Rockey, it turns out, kind of agrees with this—except that in his ideal world, people from the Jungle would have to leave their encampments to access those resources. “Putting centers in the city forces people to come to us and get access to help, and we can start a relationship,” he says. People who want to go to the Jungle to help people there, he says, are saying, essentially, “let’s keep it in the Jungle where we don’t have to see it. Let’s make it possible for people in the Jungle to commit violent acts. They don’t talk about that. They don’t talk about people living in filth that is absolutely disgusting. Giving toilets and water to someone in the Jungle meets an end, but it doesn’t solve the problem.”

Housing isn’t the only resource in short supply across King County. As with detox beds, residential treatment beds and even slots in outpatient programs are hard to come by, and the moment of clarity when an addict decides they’re willing and ready to change can slam shut as soon as the desire for the next hit outweighs the desire to get better.

In another sharp departure from the tough-love approach embraced by Rockey Finegood and Putnam espouse not just access to traditional treatment but harm reduction—making drug users and alcohol abusers safer while they continue to use. This includes novel approaches such as the safe-injection site Seattle is currently considering (and which I’ll cover in more detail in the future), as well as low-barrier shelters that don’t require sobriety but do provide access to medical care and other services.

And it includes so-called medication management, using drugs like methadone and suboxone to tamp down the urge to use by replacing heroin and other opiods with less-dangerous (but also addictive) substitutes.

“Medication assisted treatment is one of the most studied, evidence-based, proven, effective ways of treating opiate addiction,” Finegood says. “I’ve known people who’ve been on methadone for 20 years and they’ll swear it’s the main thing that’s keeping them from using heroin ever again and able to go to work every day and be a good parent.”

Rockey opposes medication management, which he sees as just another form of dependency. Rockey and the Salvation Army are hardly alone in this assessment; many recovery programs don’t consider you clean and sober if you’re dependent on suboxone or methadone, which are addictive narcotics that can be just as hard to kick as heroin.

“The people I know who try substitutes for heroin end up kicking those by going back to heroin,” Rockey says. “With suboxone, we’re not treating the root cause of the problem. Same with poverty. We have to address root causes. If simply housing is what you’re offering, that is not enough. … To me, providing dope fiends dope or providing dope fiends a needle exchange—that’s just enabling,” Rockey says.

Many clients, Rockey acknowledges, aren’t ready or willing to stick with such a rigid program, and therein lies the real answer to Westneat’s question: Why on earth does this center have empty beds? It has empty beds because a highly regimented system is not what works for everyone, and because some people aren’t ready to stop using.

The questions that answer raises, however—about what to do with people for whom treatment doesn’t work, about how to provide enough treatment beds so that they’re available when people are ready for help, about how to help people who are still using and may never stop—are the ones governments and service providers are still struggling to answer, even as the population of people who are homeless and addicted in Seattle grows.

I’ll be exploring those questions more in the coming weeks and months. Stay tuned. And if you like the work I’m doing here, please consider becoming a monthly supporter of The C Is for Crank by signing up at Patreon.