Substance Abuse and Homeless Youth

Substance Abuse and Homeless Youth

The focus of this research paper is to discuss the connection between homelessness in youth populations and substance abuse. "Homeless young adults are defined as individuals between 12 and 24 years of age who are without stable housing and who identify with the culture and economy of living on the street [1, 7-9]. Identification with street culture includes engaging in accepted practices for earning money (such as panhandling), adopting unique slang language and developing strategies to prevent victimization" (Gomez et al., 2010). Thus, with homeless youths, the homelessness is not a temporary flirtation with time away from home, but a complete and thorough transition to life on the streets. This distinction is important to make, as this paper is will be examining homeless youths: these youths are homeless by choice: either as a result of the fact that life at home had become unmanageable, or they were thrown out of the house by their parents, or because their decision to abuse drugs caused them to become homeless. The homelessness of the youths examined in this paper has gone on long enough to be considered a way of life.

Many people assume that many homeless youth have an addiction or substance abuse problem which they grapple with. While this is a stereotype to some extent, it's based on a certain level of truth. "Substance abuse is often a cause of homelessness. Addictive disorders disrupt relationships with family and friends and often cause people to lose their jobs. For people who are already struggling to pay their bills, the onset or exacerbation of an addiction may cause them to lose their housing. A 2008 survey by the United States Conference of Mayors asked 25 cities for their top three causes of homelessness. Substance abuse was the single largest cause of homelessness for single adults (reported by 68% of cities)… According to Didenko and Pankratz (2007), two-thirds of homeless people report that drugs and/or alcohol were a major reason for their becoming homeless" (NCH, 2009). If this data demonstrates anything, it shows that beyond a shadow of a doubt, there is an indelible relationship between addiction and homelessness.

When it comes to homeless youth, the relationship with substance abuse is even stronger. Some homeless youth had been kicked out of their homes because of their substance abuse problem; others were introduced to substances while they were out on the street. The fact that homeless youth are unsupervised by adults at all times means they're particularly vulnerable and at risk for a range of risky behaviors, many of which revolve around addictive substances. For example, "Homeless youth are 3 times more likely to use marijuana and 18 times more likely to use crack cocaine than non-homeless youth" (nn4youth.org). This statistic clearly demonstrates how homeless youth are indeed an incredibly at risk group who are dramatically more vulnerable than their counterparts that have homes. Back in 1997 almost twenty years ago, the problem was just as bad; in a study that was conducted of just under 500 homeless youths in Los Angeles, 71% had a problem with substances abuse (Wyman).

One of the exacerbated problems of substance abuse with homeless youth is the fact that the substance abuse acts as a tremendous obstacle in rectifying their homelessness. Furthermore, living on the streets places these vulnerable and needy kids in an environment where drugs are ubiquitous. As one veteran of teen homelessness explains, "On the streets drugs are all around you, always being offered to you, people always walkin' around smashed. I'd like to see anyone live on the streets and not take drugs at some point; I really do think that's impossible. Hey, I don't like drugs, but sometimes it's really hard not to take them. Most people on the streets have some degree of depression, and sometimes your resilience gets low" (Oldtimer, 2011). This indicates the severity of the need in addressing this issue as a societal and public health concern. For instance, this quote demonstrates that if a teenager doesn't already have a problem with drugs by the time they're on the streets, such a substance abuse problem will likely develop once they're on the streets, not simply as a result of the pervasiveness of the problem, but because living on the streets is so hard and so draining that these kids start to use drugs as a form of escapism.

The rationale for this study is based largely on need and on a problem that has long been poorly met. For instance, when it comes to homeless youth and drug surveys, homeless youth have a higher rate of drug use, drug abuse and drug experimentation (Wyman, 1997). Furthermore "Street youths were involved in more serious drug use than were youths living in shelters or at home. For instance, substantially more street youths than shelter youths used heroin and other injection drugs, methamphetamines, and crack cocaine" (Wyman, 1997). At 75%, almost all street youths use marijuana and approximately 30% use other forms of drugs including stimulants, hallucinogens and analgesics; one quarter of the youths have used or were using hard drugs like crack cocaine (Wyman, 1997). Even though these rates of drug abuse were in prevalent in late nineties, doesn't mean that the numbers are obsolete or inconsequential. If anything, the rates of drug abuse among homeless teenagers can only be expected to escalate, given the new drugs which have emerged on the marketplace and in social situations. A good example of this is the "legal highs" from designer drugs which have emerged: oxycontin is a clear example of this (at least when it first debuted on the marketplace).

Designer drugs and new prescription drugs which pack a huge punch to the brain and nervous system have become even easier to get. "Internet plays a signi-can't role for the distribution of 'legal highs', becoming one of the major 'drug market'. Adolescents and young adults who are curious about drugs may search on the Internet and thereby become exposed to thousands of sites that expound upon the positive effects of drugs and downplay or deny any negative effects. Use of mephedrone is mainly a youth phenomenon. The hazardous side-effects are strong desire to re-dose, uncomfortable changes in body temperature and heart rate, hallucinations and psychosis" (Vardakou et al., 2011). Their ease of procurement, along with their highly addictive quantity means that such drugs can easily create more addicts. More young addicts leads to the likelihood of more homeless addicts, as drug use and abuse is one common reason as to why certain teenagers are thrown out of the house by their parents.

The exacerbated need for treatment also orbits around the fact that with homeless and runaway teenagers there are a range of other conditions which of co-occur with drug abuse, such as STDs, pregnancy, depression, suicide and others. Even though a range of public health services might exist, there are still system barriers which prevent members of this select population from receiving adequate care. "In addition to the barriers experienced by the adult homeless population, homeless adolescents confront further hurdles stemming from their age and developmental stage. Some of these impediments include a lack of knowledge of clinic sites, fear of not being taken seriously, concerns about confidentiality, and fears of police or social services involvement. Improved access to appropriate health care is necessary if we are to better support and care for this population of young people" (Feldmann & Middleman, 2003). Even so, the need for care and counseling that this population presents is not being sufficiently met; part of the reason for this is because this population can't easily be considered, single and homogenous: rates of drug use even can vary widely depending on factors like age, gender and race.

However, one facet is generally agreed upon: in order to better reach this vulnerable population and in order to get a large portion of this population receiving treatment, there simply needs to be greater visibility of service providers -- in number and in mode of service. For example, vans which provide outreach staff well educated in forms of drug treatment and counseling that can travel to areas where youth congregate is an example of an effective means or attempt at service.

In the past few years, the numbers of homeless youth have increased as a result of the fledgling economy. "Over the past two years, government officials and experts have seen an increasing number of children leave home for life on the streets, including many under 13. Foreclosures, layoffs, rising food and fuel prices and inadequate supplies of low-cost housing have stretched families to the extreme, and those pressures have trickled down to teenagers and preteens" (Urbina, 2009). While many of these kids don't necessarily have a drug problem, once they're homeless, they become at a high risk for developing one, given the fact that drugs are so prevalent on the streets.

Complexities of Assessment

When it comes to treating homeless youth with substance abuse issues, there can be various factors which impact making an accurate assessment of their needs. For some, there will be a denial and minimization of the substance habit as being inconsequential, purely recreational or extremely intermittent. This response is akin to the young adult asserting that there is no problem. For other homeless youths, their drug or alcohol habit maybe viewed as a form of survival: these drugs help these teenagers bear life on the street. In that sense the substance is attributed as beneficial for the escapism necessary to survival. "Using, even abusing substances is often viewed as a 'normal' practice by those identifying with street culture. Homeless young people report using drugs and alcohol as a coping strategy and often have more favorable attitudes toward drug use than their non-homeless peers" (Gomez et al., 2010). Thus, there could be a complete difficulty in making any assessments, since many homeless youths won't see their substance abuse as a problem at all, and won't seek treatment, viewing it instead as merely an indelible feature of life on the street.

For other youths, making accurate clinical assessments becomes even more difficult because of the varying reasons for why the youth is homeless. For some youths, the homelessness is a result of the fact that they had to leave a bad home situation and find life on the streets to be an improvement. As one youth described her home life: "I'm just tired of it all, and I don't want to be in my house anymore," she said, explaining why she had run away. "One month there is money, and the next month there is none. One day, she is taking it out on me and hitting me, and the next day she is ignoring me. it's more stable out here" (Urbina, 2009).

Another issue which makes assessment difficult is that some researchers have found that the drug use of homeless youths to be all over the map. Some became homeless because of their addiction problem, some became addicted as a result of living on the street, and others became addicted because of exposure to parental drug use and others because of environmental or situational factors.

Impact of Drug Use on Homeless Youths

Drugs and drug abuse don't solve problems they create new ones and for homeless youths this is particularly the case. Drug abuse with this population causes them to need to support an expensive habit, when they're already fighting to forge their own survival as it is. Drug abuse puts members of this population at risk for a range of associated conditions and maladies. "Drug use is believed to be an important factor contributing to the poor health and increased mortality risk that has been widely observed among homeless individuals [1,2]. Substance use may increase the risk of homelessness by undermining their social ties and economic stability [3]. Drug users also suffer from numerous adverse health effects, including overdoses, psychiatric conditions, and infectious diseases" (Grinman, 2010). Furthermore, the work of Grinman and associates found that drug use among homeless teens often set them up for lifetime use as was found in one study (2010). This element was exacerbated by the fact that many homeless youths failed to identify that their drug problem was an obstacle in them securing permanent housing (Grinman, 2010).

The maladies and health concerns that fester in this specific population are both related to practical issues -- not having a warm place to sleep and not getting enough to eat -- along with certain indelible factors related to a homeless lifestyle. For instance, unprotected sex or sex with multiple partners as a result of carelessness, lack of education or involvement in the sex industry, is a definitive part of homeless life for many of these youths. "Moreover, the experience of homelessness appears to have numerous adverse implications and to affect neurocognitive development and academics, as well as mental and physical health. Substance use, sexually transmitted infections, and psychiatric disorders are particularly prevalent in this population. Whereas some of these problems may be short-lived, the chronic stress and deprivation associated with homelessness may have long-term effects on development and functioning" (Edidin, 2012). Just as some of the health effects of homelessness and drug use might be short-lived or temporary for this population, many of them might lead to lasting developmental issues that could follow the individual for life.

Another finding in regards to homeless youths and drug abuse is the fact that this population has been found to have a significantly poorer mental health status (Grinman, 2010). At this time, it's not clear whether this lower level of mental health was as a result of the drug use, or if the drug use was a result of the precarious mental health status -- or if this relationship can be summarized as a hybrid of the two factors.

Another factor which truly should be examined is how large a factor societal estrangement is on this particular population, as it is commonly associated with substance use (Thompson, 2010). In fact, the study entitled, "Estrangement factors associated with addiction to alcohol and drugs among homeless youth in three U.S. cities" attempted to pinpoint the four specific arenas of social estrangement -- disaffiliation, human capital, identification with homeless culture and psychological dysfunction -- in connection with substance abuse (Thompson, 2010). "Homeless young adults were recruited from three disparate urban areas: Los Angeles, CA (n = 50), Austin, TX (n = 50) and St. Louis, MO (n = 46) using comparable research methods and measurement instruments. Findings demonstrated that variables measuring psychological dysfunction and homeless culture predicted alcohol addiction, while institutional disaffiliation and homeless culture predicted drug addiction" (Thompson, 2010). Both substances (drugs and alcohol) were found to offer distinct patterns of estrangement for youths in all major cities (Thompson, 2010). One can only guess how such patterns of estrangement can only solidify a youth's involvement in homeless culture and drug culture, making this separation from regular society even more aggravated. Thus, one can conclude that isolation and societal estrangement are not only impacts of substance abuse with homeless youth, but are factors which act as formidable obstacles from youth receiving care.

In many youths, it has been found that post-traumatic stress disorder is a health concern they suffer from. While more research needs to be conducted in to the exact factors of this issue, it truly comes as hardly a surprise at all. Severe abuse is a common reason that youths leave home, and thus it makes sense that they would suffer from PTSD. It also is fitting that if homeless youths are thus suffering from PTSD, they would be more likely to engage in drugs in a recreational or abusive fashion. In fact, the study, "Factors associated with trauma and posttraumatic stress disorder among homeless youth in three U.S. cities" by Bender and associates, examines this factor exactly (2010). This particular study "…examined correlates of trauma and PTSD among homeless youth with a focus on the impact of homeless culture, substance addiction, and mental health challenges. Homeless youth (N = 146) from Los Angeles, California, Denver, Colorado, and St. Louis, Missouri, were recruited from organizations providing services to homeless youth using comparable methods. Results indicate that 57% of respondents had experienced a traumatic event and 24% met criteria for PTSD. A multinomial logistic regression model revealed greater transience, alcohol addiction, mania, and lower self-efficacy predicted PTSD whereas trauma exposure was associated with alcohol addiction only" (Bender et al., 2010), Thus, the research reflects that with homeless youths, PTSD is another health condition which often co-occurs with the substance abuse, or which acts as the reason for why substance abuse develops in the first place.

Current Evidence-Based Treatment

Certain therapeutic Communities (TCs) have developed for this population in various formats, both in-patient and out-patient therapy. "Modified TC programs for homeless individuals, often developed in shelter settings, have tended to incorporate auxiliary services to address clients' multiple needs, such as educational, vocational, legal, and housing placement services. Other fundamental differences include a greater degree of flexibility and less intensity or confrontation than one would see in more traditional TCs" (Zerger, 2002). These therapeutic communities feature group settings and a following of a 12-step recovery format as well as other flexible modifications to meet the needs of this specific community. For instance, certain in-patient programs have found that homeless, addicted teens are in need of more guidance and assistance and support throughout their recovery process. Certain centers treat a potential or actual relapse as part of the recovery process and just another stepping stone in the path to getting better. Others view a relapse as a sign that previous therapy had been ineffective.

However, as one scholar illuminates, the literature on treating homeless, substance abusing youth is more revelatory about what is not known than about what is and much of the literature reflects that (Slesnick, 2004). Currently, the bulk of all treatment programs center around 12 step processes such as alcoholic anonymous or narcotic anonymous. Such 12 step programs can be effective; it's just that they can't be the only answer with the specific population. The needs of homeless youth are different than the needs of homeless adults; the same goes for the needs of drug-addicted youths as opposed to drug addicted adults. 12 step programs represent good starting points for treatment of this specific population, but they are certainly not enough.

Solution-Focused Brief Therapy

Solution focused brief therapy is an ideal tactic of treatment for this specific population. This type of therapy has a clear and immediate focus and does not occur indefinitely, elements which are ideal for this particular group. Solution-focused brief therapy can be viewed as a form of therapy which is akin to a physical therapy with someone who has a muscular or joint issue. A problem is focused upon, along with a specific solution as to how to address the problem. The problem is then worked and worked until all traces of the problem are eliminated -- in these cases youths would be living in some form of housing and not using or abusing drugs. "Solution-focused brief therapy is an approach to psychotherapy based on solution-building rather than problem-solving. It explores current resources and future hopes rather than present problems and past causes and typically involves only three to five sessions. It has great value as a preliminary and often sufficient intervention and can be used safely as an adjunct to other treatments. Developed at the Brief Family Therapy Center, Milwaukee (de Shazer et al., 1986), it originated in an interest in the inconsistencies to be found in problem behavior" (Iveson, 2012). While this type of therapy is not always effective and there are exceptions to its effectiveness time after time, many times the exceptions will contain trace elements of the client's own personal solution (Iveson, 2012).

Another factor which makes this type of therapy particularly effective is that because it's so goal oriented, clients see a definitive end in sight, knowing that their achievements will be well served, and that all interventions will be made (Iveson, 2012). Thus, this type of therapy has long been effective for drug abuse and homelessness among a range of other problems and severe issues.

Another overwhelming advantage of this type of therapy is that it's simple and low cost. There's already a considerable amount of evidence which speaks to its effectiveness and the wide range of populations that it applies to, particularly with homeless youth and teenagers in transition (such as previously homeless youth (Mares, 2009). The simplicity of this form of therapy should not be underestimated, as comparable clinical approaches are generally much more complex (Mares, 2009). Furthermore, solution-focused interventions have been found to be effective with both individuals and groups (Mares, 2009). Moreover, there's an aspect of this type of therapy which is simply going to be more attractive to homeless youths; it has to do with where the emphasis is placed. In solution-focused interventions, "the emphasis placed on existing strengths is common within social work practice. Finally, de-emphasized concepts of pathology and clinical diagnoses, are likely to be more attractive to middle to higher-level functioning youth in transition as a low-intensity, 'step-down' level of aftercare assistance and support" (Mares, 2009). Thus, as this excerpt demonstrates, there's a level of practicality which pervades this type of therapy and which will make it more conducive to working effectively with the homeless population that suffer from these types of issues.

The professional health communities who work with this population of homeless, often drug -- addicted youths, generally applaud the use of solution-focused therapy as a means of effectively treating this population. "Solution-focused brief therapy (SFBT) is a strength-based model that utilizes a cognitive-behavioral approach to help clients imagine how s/he 'would like things to be different and what it will take to make that happen' (Gingerich, 2000, p. 476). Although SFBT has not been examined as a treatment approach for PTSD, or as an intervention with homeless youth, several authors (De Rosa et al., 1999; de Winter & Noom, 2003; Greene, Lee, Trask, & Rheinscheld, 1996; Kidd, 2003; Rew, 2002) support the use of strength-based and solution-focused therapeutic approaches for homeless youth because these approaches focus on mobilizing the strengths and resources of the client" (McManus & Thompson, 2008). Such an excerpt already demonstrates why this type of therapy is successful; it focuses on self-empowerment. The individual is encouraged to think about how things could be different and what he could do to facilitate that process. The individual, often a disadvantaged child who has suffered from untold abuse and enormous suffering, needs permission to be able to imagine a better life for him or herself. This type of therapy adequately harnesses upon that kind of dreaming and imagery along with the practical tools needed to accomplish one's goals.

Runaway and homeless youth can readily benefit from the conglomeration of solution-focused ideas in terms of a crisis intervention model, as a form of a logistical framework (McManus & Thompson, 2008). Using this method of treatment means that the clinician has to actively make the assumption that the solution, or some part of the solution is within the reach of the client; in this way the focus can stay on empowerment and the harnessing of available resources so that the current problem can be accurately dealt with (McManus & Thompson, 2008). However, one of the more powerful aspects of this method is that the focus on self-empowerment, and the emphasis on minimizing the problem at hand create concrete expectations for change (McManus & Thompson, 2008). Expectations for change can be tremendously influential in starting the initial steps towards transformation with small changes and the momentum for larger changes (McManus & Thompson, 2008).

Another truly powerful aspect of this program is the fact that the language used by the clinician is incredibly precise, harnessing the power of suppositional language so that hope for the future can be sparked (McManus & Thompson, 2008). "An SFBT approach facilitates the youth in defining, evaluating, and developing his/her own goals and strategies to attain them, which serves to reinforce his/her sense of autonomy. Levy (1998)recommends the following SFBT-oriented questions to facilitate this process: 'What changes would you like to see in your life? If you had three wishes to change your current situation, what would you wish for? If a miracle were to happen today, what would be different?' A solution-focused approach recommends following up these questions by exploring how current behaviors link with identified goals" (McManus & Thompson, 2008). This particular form of therapy can be quite so effective because it harnesses a value that's incredibly important to the youth as it is: autonomy.

Homeless youths, be them addicted to drugs or not, all value their autonomy and independence. This form of therapy which capitalizes on these elements is ideal, as it harnesses positive qualities that homeless youths have inherently, and promote inherently in their own lives. It allows these youths to see that by getting better, they're not giving up qualities that they value so intensely, but rather drawing upon these qualities to flush their lives with a greater level of positivity.

Motivational Therapy

Much research has been conducted on the impact of motivational therapy with homeless youth who have addiction issues. For instance, the authors of the study, "Brief motivational intervention with homeless adolescents" by Baer and colleagues examine the impact of such a technique on a sample of 117 homeless adolescents (2007). In this study, which took a randomized design and a three-month follow up, was created to bolster the concerns of the youth about their substance abuse, encourage hard reduction and motivate them to utilize service more wildly from helpful agencies. Based on the data collected, "Analyses revealed no significant benefits for intervention participants when homeless youths' substance use rates were compared with those of control participants. Service utilization during the intervention period increased for those receiving the intervention but returned to baseline levels at follow-up. Participants reported overall reductions in substance use over time" (Baer et al., 2007). While motivational therapy didn't create instant results, the more gradual changes that occurred indicated that the transformations that the youths in this sample had undergone were more permanent and lasting. Moreover, the researchers of this study take a very specific and realistic look at the limitations of this type of treatment, as those limitations manifested with the youths of this population (Baer et al., 2007). The researchers also indicate promising changes that need to take place in future research with this technique to fine-tune it so that it's more effective and responsive to a variety of vulnerable youth.

Prior to this study, Baer and colleagues had conducted a comparable research study which examined simply the short-term results of this exact type of treatment on addicted youth and homeless youth with substance issues. The results of that particular finding were very promising, demonstrating even the short-term efficacy of motivational therapy for such youths. Baer and colleagues recruited a total of 285 teenagers from ages 14 to 19 from centers all around the city (2006). Each youth received one session of a motivational intervention and personal feedback about patterns of risks in connection with alcohol or substance abuse in a manner that was comparable to motivational interviewing, with follow up interviews occurring one to three months later (Baer, 2006).

"Youths who received the motivational intervention reported reduced illicit drug use other than marijuana at 1-month follow-up compared with youths in the control groups. Treatment effects were not found with respect to alcohol or marijuana. Post hoc analyses within the ME group suggested that those who were rated as more engaged and more likely to benefit showed greater drug use reduction than did those rated as less engaged" (Baer et al., 2006). The potential of this particular type of therapy is truly enormous when one considers its sheer effectiveness. If homeless youths can make positive changes in their consumption of drugs or alcohol after just a single session or motivational therapy, then one can only imagine the changes that can be made and all that can be accomplished after a month's worth of sessions. Moreover, these changes demonstrate some of the sheer power of expressing interest in the life of a troubled child. Many of these addicted, homeless youths simply didn't have parents who cared about them in the way that they needed to be cared about -- they weren't nurtured and they weren't looked after very well and a great deal of their addiction is connected to numbing out emotional pain.

As Dr. Gabor Mate has pointed out, "Addictions always originate in unhappiness, even if hidden. They are emotional anesthetics; they numb pain. The first question -- always -- is not 'Why the addiction?' But 'Why the pain?'" (Mate, 2007). This question can be readily asked of homeless youths as it is tremendously relevant. Many of them have ended up homeless as a result of broken, abusive homes. Many of the homeless youths examined in this research engaged in drug habits to numb themselves from a lack of attention or affection -- habits which ultimately got them kicked out of the homes they originated from. As Mate explains, as a staff physician at Portland non-profit harm reduction facility where many patients are addicted to hard drugs like, cocaine, heroin or tranquilizers her prescribes methadone for opiate dependence, which "does little for the emotional anguish compressed in every heartbeat of these driven souls" (2007). If Mate is correct, and given his decades of experience and his clinical expertise, it seems likely that he is, then this explains why forms of treatment like motivational therapy can be so effective with homeless youths as it fills in an emotional need that many of them have never had fulfilled by an adult before.