In the Spring of 2006, a student named Masuma Bahora wrote a thesis in partial satisfaction of the requirements for the degree of Master of Public Health in the Department of Behavioral Sciences and Health Education in the Rollins School of Public Health in the Graduate Division of the University of California at Berkeley. Titled “Investing in the Narrative: Perceptions & Attitudes of Substance Use among Homeless Youth in Berkeley, California,” this study methodically explores the culture of substance use among Berkeley street youth, informed by Masuma’s experiences with the Suitcase Clinic while serving as an Americorps volunteer. “Acknowledging the limited research on the larger context in which these youth operate, this study explores the experiences, perceptions, and motivations surrounding personal substance use among this population.” Her thoughtful investigation makes extensive reference to data collected at the Suitcase Clinic’s Youth Clinic, and represents another crucial piece of scholarship on our organization’s mission and efficacy. Masuma has contributed richly to the Suitcase Clinic’s growing body of professional literature by making this document available.
The entirety of her study can be read below in a search engine-friendly format:
Investing in the Narrative:
Perceptions & Attitudes of Substance Use
among Homeless Youth in Berkeley, California
By
Masuma Bahora
B.A, Washington University in St. Louis, 2003
A report submitted to the
Department of Behavioral Sciences and Health Education
Rollins School of Public Health
In partial fulfillment of the requirements of the degree of
Master of Public Health
2006
Investing in the Narrative:
Perceptions & Attitudes of Substance Use among Homeless Youth in Berkeley, California
APPROVED
Claire E. Sterk, Ph.D. Thesis Chairperson Date
Alan B. Steinbach, Ph.D., M.D. Thesis Committee Member Date
Richard M. Levinson, Ph.D., Interim Chair – Dept of Behavioral Sciences & Health Ed
In presenting this report as a partial fulfillment of the requirements for an advanced degree from Emory University, I agree that the Rollins School of Public Health shall make it available for inspection and circulation in accordance with its regulations governing materials of this type. I agree that permission to copy from, or to publish, this report may be granted by the professor under whose direction it was written, or in her absence, by the Chair of the Department of Behavioral Sciences and Health Education, when such copying or publication is solely for scholarly purposes and that any copying from, or publication of, this report which involves potential financial gain will not be allowed without written permission.
Masuma Bahora Date
NOTICE TO BORROWERS
Unpublished papers deposited in the Rollins School of Public Health of Emory University must be used only in accordance with the stipulations prescribed by the author in the preceding statement.
The author of this thesis is:
Masuma Bahora
1203 Euclid Ave #3
Atlanta, GA 30307
The thesis Chairperson of this report is:
Claire Sterk, Ph.D.
Department of Behavioral Sciences and Health Education
Rollins School of Public Health
Emory University
1518 Clifton Road, N.E.
Atlanta, GA 30322
Users of this report are required to attest acceptance of the preceding stipulations by signing below.
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Acknowledgements
I would first like to thank my thesis advisor Dr. Claire Sterk, whose kind support and remarkable patience enabled me to reach complete and enjoy this process. She permitted this to be my own work, but continually provided me guidance when I needed it, and the enthusiasm to let me know I was on the right track. I would also like to thank Dr. Alan Steinbach who helped me process my thoughts, steady my emotions, and had the calmness to trust that something positive would come out of my time in Berkeley.
During my time in Berkeley, I was grateful to have met two individuals: Elizabeth Marlow and Dr. Deena Neff. It was their insight and commitment to patients that not only inspired me throughout my year in Berkeley, but motivated me to return the next summer. It is important that I also thank Morgan Fitzpatrick, the Youth Suitcase Clinic staff, and the numerous Berkeley area service providers who are committed to advocacy and change, regardless of the difficulty of the path ahead.
I also want to express my appreciation to my friends and family whose input, ingeniousness, and laughter, though often from miles away, I could not have done without.
Lastly, I would like to thank all of the participants and other youth who let me in, shared their incredible experiences, and encouraged me to have faith that things could and do change. This thesis is dedicated to them.
Masuma Bahora
Abstract
Background: Low admission and retention rates among homeless youth in substance use treatment facilities warrant a closer examination to identify factors that contribute to this alarming trend. This trend is especially salient given that many of these youth are at a substantially higher risk for transitioning into an older, and often harder to reach, homeless population. Acknowledging the limited research on the larger context in which these youth operate, this study explores the experiences, perceptions, and motivations surrounding personal substance use among this population.
Methodology: Semi-structured interviews were conducted with 29 non-shelter based street youth, aged 14-24 years old, in Berkeley, California during the summer of 2005. Topics covered included daily life structure, perceptions of substance use and addiction, the temporal aspects of homelessness, and behavior change processes. MAXqda2 was utilized for data management, while the constant comparison method, common in grounded theory, guided data analysis.
Results: Results reveal that participants perceived a sense of control in their pathways to homelessness, reasons to use substances, and motivations to change their substance using behavior. Additionally, many participants described the peripheral nature of substance use in their lives, expressing the greater influence of such factors as social support and drive toward future goals. Participants also discussed four main components that they deemed necessary when considering entering substance abuse treatment facilities: flexibility, stability, experienced staff, and a sense of community.
Conclusions: Study findings provided insight into the role perceived control plays in youths’ transition to the street and use of substances, indicating that future interventions should support the decision-making ability of homeless youth. These findings also suggest the need to re-examine current treatment models’ policies, considering the importance of flexible treatment goals, and the value of providing general support services in lieu of services directed solely on reducing substance use. The study findings are important for the development of appropriate services targeting homeless youth and they serve as baseline findings for policy makers, as well as social and health care providers.
Table of Contents
List of Appendices………………………………………………………………………..9
Introduction 10
Definitions 12
Review of Literature 13
Methods 18
Participants 18
Measures 19
Procedures 20
Analysis 20
Results 22
Choice & Perceived Control 22
Perceived control and choosing to be homelessness 22
Perceived control and reasons for staying homeless 24
Control and rationale for using substances 25
Control and trigger to change usage 29
Element of Change 31
Desire and readiness to change 31
Rationale and unwillingness to change 34
Barriers to change 39
Future of Treatment 42
Flexibility. 42
Stability 45
Experienced staff 46
Community 46
Discussion 49
Conclusions 49
Limitations 54
Implications 55
Recommendations for Future Research 56
References 57
Appendices 62
List of Appendices
Appendix A: Verbal Consent Script ……………………………………………………….62
Appendix B: Interview Guide…..………………………………………………………….64
Appendix C: Coding Tree ………………………………………………………………….6
Introduction
Recent estimates indicate that youth between the ages of 16 and 24, account for nearly 12 percent of the homeless population (Burt, et al., 2001). This number is especially alarming given reports from the greater San Francisco area documenting that youth between the ages of 18-24 have the highest poverty rates of any group and are consequently the fastest growing segment of the homeless population (National Alliance to End Homelessness, n.d.). These homeless youth are an often understudied yet salient population due to both their precarious living situations and risk-taking behaviors. The environments in which these youth reside place them at a significantly greater risk for a multitude of health perils including substance abuse.
Epidemiological studies have reported increasingly high prevalence of substance abuse among homeless youth compared to their housed counterparts. A Los Angeles-based study of the prevalence of mental illness among homeless youth Kipke, Montgomery, Simon, Unger and Johnson (1997) found that nearly 70% of their street youth sample fit DSM III criteria for having an alcohol or drug abuse disorder, while 31% had both. Additional research has shown that a growing number of homeless youth who engage in risky behaviors such as substance use are less likely to access and utilize housing and health services (Robertson & Clark, 1995). Among the 18 to 24 year old group, substance abuse treatment needs often go unmet due to ineligibility for treatment in children’s service systems, and inappropriate and inadequate treatment offered in older adult service systems (Robertson & Toro, 1999). These studies demonstrate two points: homeless youth have an obvious need for services such as substance abuse treatment, but are not likely to access and utilize these programs.
The reasons homeless youth do not participate in substance abuse treatment programs, despite their apparent needs, remain unexplored in available research. Research investigating substance abuse among homeless youth has thus far yielded answers to questions of the who, what, and how of substance use among homeless youth, in essence documenting trends. Current available research has been unable to answer ‘why’ these homeless youth use substances. Without this knowledge, service providers are unable to appropriately assess, intervene, or treat this population’s problems. The present qualitative study gives context to homeless youths’ substance use by focusing on the subjective experiences that propagate these trends. By exploring substance use, not as an isolated component in many of these homeless youths’ lives, but instead as an issue that is intertwined as well as both causal and/or consequential of many other factors that affect this population, this study aims to understand their resulting substance use treatment needs.
Definitions
• Homeless: An individual is defined as homeless if he/she was staying in an emergency shelter, or transitional housing, living on the street or in a car, or who would lose their housing within a month, and have nowhere else to go. This definition was utilized due to its adoption by Alameda County (Alameda Countywide Homeless and Special Needs Housing Plan, 2005, p.51).
• Youth: An individual between the ages of 14 to 24. Age cutoffs were designated to reflect restrictions of age set by local youth service providers.
• Substance Use: Substance use, for the purpose of this study, was defined as using any drug that is normatively defined by society as being illicit. Though alcohol use for underage populations is illegal, substance use did not include alcohol use due to the recognition of the pervasiveness of alcohol accessibility and consumption in this population.
Review of Literature
Current national estimates of the number of homeless youth range from 500,000 to 1.6 million (Ringwalt, Greene, Robertson, & McPheeters, 1998). The actual heterogeneity of this population has made an accurate picture of this population difficult to obtain and interpret (Ringwalt et al., 1998). Due in large part to the variety of criteria and parameters used to describe homeless youth, interchanging terms as runaways, throwaways, and street youth, sampling from a multitude of locations such as shelters, service agencies, and/or street based sites, and employing different age cutoffs to describe an adolescent or youth population, no reliable estimates are available regarding the prevalence of homelessness among youth. However examining the topics of research that have been formerly conducted with this population will lay a groundwork for understanding the context in which substance use occurs in the lives of these homeless youth.
Previous research demonstrates that homeless youth leave home due to a variety of reasons including family conflict, neglect, escape from maltreatment (both physical and sexual abuse), and parental drug use (Bao, Whitbeck, & Hoyt, 2000; Hyde, 2005; Kipke et al., 1997b; Mallett, Rosenthal, & Keys, 2005; Noell, Rohde, Seeley, & Ochs, 2001). Further, either independently or as a result of these past experiences, additional research has documented the disproportionately higher risks and rates of negative physical and mental health issues that affect this population including Hepatitis B and C (Beech, Myers, & Beech, 2002); malnutrition (Rew, 1996), sexually transmitted infections (STIs) (Noell et al., 2001; Rew, 1996); HIV infection (Rotheram-Borus et al., 2003); as well as depression (Ayerst, 1999; Smart & Walsh, 1993; Whitbeck, Hoyt, & Bao, 2000); dissociation and post traumatic stress disorder (Whitbeck, Johnson, Hoyt & Cauce, 2004); and suicide ideation (Kidd, 2004; Molnar, Sharde, Kral, Booth, & Watters, 1998) in comparison to housed youth of similar age.
Researchers have continued to build on these studies by asking why homeless youths’ health needs often go unmet compared to the needs of housed youth. Research conducted in this arena cite reasons such as lack of insurance, inadequacy of services, accessibility, competing needs, a distrust of authority, availability, as well as confidentiality issues (Klein et al., 2000; Barkin, Balkrishnan, Manuel, Andersen, & Gelberg, 2003; Ensign and Gittelsohn, 1998; Geber, 1997; Harris et al., 2003). Translating these results into application, researchers have sought to emphasize that because this population is hard to reach, and has relatively low levels of service utilization, comprehensive and tailored interventions are required to address their needs. These interventions, however, are futile without an understanding of the behaviors that result in disproportionate negative health outcomes.
In more recent years, a growing body of literature has drawn attention to the range of behaviors, in which homeless youth engage, that put them at risk for unwanted pregnancies, sexually transmitted infections, and HIV, including substance use. A substantial amount of research on substance using homeless youth has documented the increased prevalence of substance use in this population relative to youth who are housed (Greene, Ennett, & Ringwalt, 1997; Kral, 1997; Smart & Adalf, 1991; Unger, Kipke, Simon, & Montgomery & Johnson, 1997; Rew, 2001). Additional research has shown that not only do homeless youth significantly differ in their extensive exposure to drugs, compared to their non-homeless counterparts, but also in the severity or extent by which they are involved with these drugs (Baer, Ginzler, & Peterson, 2003; Kipke, Montgomery, Simon, Unger, & Johnson, 1997). Building upon these studies, researchers have shown that youth who meet criteria for substance abuse often also meet criteria for post-traumatic stress disorder (Johnson, Whitbeck, & Hoyt, 2005) and are at risk for other mental disorders including suicide ideation, depression, and self-esteem (Unger et al., 1997). For some, the effects of substance use/misuse may lead to symptoms of mental illness for others, mental health issues may lead to abuse of substances in an effort to cope with their current stressors (Auerswald & Eyre, 2002; Fisher, Florsheim, & Sheetz, 2005; Kidd, 2003; Mallett, Rosenthal, & Keys, 2005).
Studies exploring factors that may contribute to the relatively high levels of substance use among homeless youth have shown nuances that may exist within their substance using patterns. In this way, findings suggest that HIV risk-related behaviors, length of homelessness, and exposure to street culture are influenced and vary by types of substances used, route of administration, and severity of use (Gleghorn, Marx, Vittinghoff, & Katz, 1998; Milburn, Rotheram-Borus, Rice, Mallet, & Rosenthal, 2006). Among numerous factors, peers, social networks, and group affiliations have emerged as an important presence in the adoption of substance use among homeless youth (Ennett, Bailey, & Federman, 1999; Kipke et al., 1997; Rice, Milburn, Rotheram-Borus, Mallett, & Rosenthal, 2005).
Although these descriptive studies speak to a pressing need for substance use treatment, many existing treatment facilities remain underutilized by substance using street youth (Milburn et al., 2006; De Rosa et al., 1999; Robertson, Koegel, & Ferguson, 1989; Smart & Ogborne, 1994; Robertson & Toro, 1999). To date, only one study explores the plausibility of difference in perspective with regard to substance use among homeless youth; Fisher and colleagues (2005) report that despite high rates of substance use among study participants, very few of these youth considered their substance use pattern problematic. This study reports a point of divergence between what street youth perceive as problematic and what psychometric measures indicate as clinically significant. However, the study fails to capture the subjective experiences influencing their participants’ responses and thereby falls short in giving context to street youths’ perspectives surrounding personal substance use.
Ethnographic methods permit researchers to capture experiences in vulnerable populations whose stigmatized behaviors do not readily present themselves otherwise (Bourgois, Lettiere, & Quesada, 1997; Sterk, Elifson, & Theall, 2000). This study aims to examine the meaning these youth give their experiences, perceptions, and motivations surrounding personal substance use. An examination of these narratives through the voices of the youth has the potential to provide knowledge that can inform appropriate prevention, intervention, and treatment services. This paper seeks to address gaps in existing knowledge by exploring substance use in the context of the lives of homeless youths.
Methods
This study was carried out with a street population of homeless youth, who were ‘bedding down’ in Berkeley, California during any point in time between May 2005 and July 2005. Berkeley is situated in Alameda County which also contains Oakland, California and has an overall population of 102,049 (US Census, 2003). Current estimates, from an Alameda Countywide Shelter and Services Survey, indicate that in Alameda County alone 6,215 people are homeless at any given time and that approximately one-eighth of them utilize services and housing opportunities (Speiglman & Norris, 2004, p.3-8). One limitation of this 2004 survey is its inability to capture data from people who become homeless and then housed again over a year long period. This same survey, however, reports that Alameda Countywide Homeless Continuum of Care Council estimates that 16,000 people experience homelessness annually (2004, p.1-2). Unfortunately, no data are available on homelessness among youth.
Participants
Between May 2005 and August 2005, in-depth open-ended interviews were conducted with twenty-nine homeless youth (10 females, 19 males). Eligibility criteria required study participants to: (a) be currently homeless (b) be 14-24 years of age, (c) self-report use of substances (current or past), and (d) be able to give verbal consent to participate. The mean age was 22.12 years (range 15-24 years), and 85.1% were self-identified Caucasian. Length of homelessness for this population spanned from one year to thirteen years with the average being 4.7 years. Of the 62.96% of youth who self-identified as intravenous drug users (IDU), 100% of these youth were also poly-substance users. When asked specifically about the substances they currently used, 44% of the youths responded that they used heroin, while 55.96% of the youths reported methamphetamine use. Just over 59% of respondents reported using marijuana.
Measures
Each interviewee was asked to assign themselves a pseudonym that was then attached to all of their corresponding documentation. To reduce the trail of paperwork that was associated with the interviewee, verbal consent was obtained prior to the interview (see Appendix A). All study materials, including the verbal consent script and interview guide, were approved by the Emory University Institutional Review Board, prior to the start of the study. Before taking part in the study, participants were informed any identifying information would be changed to protect their confidentiality.
Open-ended interviews were semi-structured in design, and initially asked youth to elaborate on how they became homeless and began using drugs. Additional topics and questions that were covered varied according to the respondent and included matters such as initial and subsequent substance use, youths’ perceptions of their own substance use, and prior experiences with treatment facilities. Youth were also asked about topics unrelated to their substance use to get a greater picture of the context within which youth negotiated their existence. Interviews typically ran 45 minutes to one and a half hours in length. Respondents were offered the choice of a phone card or a meal in compensation for their time.
The grounded theory design was utilized due to its methodology of deriving a theory from the data itself. Grounded theory not only explores the behavior as the participant does, but how that participant then responds to the dynamic conditions surrounding the behavior, as well as the consequences of their actions. It was this interaction that the researcher hoped to capture and conceptualize (Strauss, 1990). Further, due to the difficulty in accessing this marginalized population and the lack of information about this population, qualitative research was deemed more appropriate for describing their experiences and perceptions.
Procedures
Potential respondents were recruited primarily from street-based sites due to the interest of surveying diverse subpopulations of homeless youth, many of whom did not utilize shelter or clinic services. Using convenience sampling techniques, as the population shifted locations day to day, these street-based sites included sidewalks, corners along Telegraph and Shattuck Avenue, as well as park benches in the historic People’s Park, areas where youth often panhandled and/or congregated. Very few eligible youth chose to not participate (n=3) citing time constraints as they were leaving town. Once a respondent was identified as eligible, interviews generally took place immediately or were scheduled for a later time that same day. Interviews took place at locations convenient to the study participants such as local coffee shops, bus stops, or on the steps of area churches.
All data were collected by the principal investigator who had worked as an outreach worker with the homeless youth population in this area the year prior to commencement of data collection.
Analysis
Analysis took place simultaneously with data collection, and was used to direct the next interview. The research process, in this way, guided the researcher’s methods, allowing the interview guide to become increasingly focused (see Appendix B). Interviews were audio-taped and transcribed verbatim by the principal investigator. Transcripts were then entered into MAXqda2, a qualitative data management software program. From these transcripts, initial analysis involved using an inductive approach to identify prevalent themes, such as barriers to substance use change and types of social support, from which a coding tree was created (See Appendix C). Secondary and tertiary analysis investigated the interactions between these themes, or codes, looking across the data. This process, parallel to the constant comparative method, uses preliminary themes to guide analysis, and then confirms the presence of these themes within the data itself.
Results
Choice & Perceived Control
Among the majority of respondents, perceived control emerged as a salient theme. Frequently, perceived control was defined as having the capability to make a deliberate decision in a state of awareness of one’s surrounding situation. In reference to being homeless and/or being a substance user, the respondents often associated this control with the ability to make a choice. In turn, choice was linked to being able to exert control over their life. Four main areas in which respondents described having perceived control were: their pathways to becoming homeless, their reasons for continuing to be homeless, their current substance use, and their reasons for changing their pattern of substance use.
Perceived control and choosing to be homelessness. Nearly three quarters of the respondents in this study explained that their status as a homeless individual was derived from a personal choice. Often, the choice to be homeless was triggered by the desire to separate from the parental home or from an institutional setting. These two situations led to a choice impacting their pathway to homelessness.
Among the key reasons to leave the parental home were the desires to seek independence and determine one’s own destiny. For some of these respondents, the push for freedom and drive toward homelessness was triggered by a sense of boredom with their current situation. Moreover, study participants who spoke about having been bored at home associated this with a lack of engagement by parental figures.
Among the majority of respondents a main theme that motivated departure from home was disagreements with adult guardians. Few respondents were either willing or able to elaborate on the exact nature of such disagreements noting that conflicts often concerned arbitrary topics. They made comments indicating that they “did not get along,” “argued,” and “fought.” In a number of instances disagreements escalated to abuse. Hudson recounted that difficulties emerged as his parents were divorcing and he opted to live with his father. Soon after moving in, his father became abusive. He explained:
The first time I was homeless, I was seventeen. I had a rocky relationship with my dad and step mom…the black sheep of the family. I left the house willingly, when I was seventeen, due to an unfit environment – verbal, physical…you know? And uhh, I tolerated it to a point, then I just left. I left it in the way I wanted it to be, I guess.
Hudson illustrates that his choice to part from his parents was one he had made, perceiving himself as having control over the situation he was unwilling to bear. Aspen, a 24-year-old female, left home at the age of eleven to live in the silos and underground tunnels of Denver. Due to a parent that was physically abusive, she explained her decision to leave as one where she could either lash out or gain control of herself by leaving the situation altogether.
I ran away when I was eleven…kinda because my mom and dad were separating and shit – and I was a Daddy’s girl – and my mom was a horrid piece of a mother, you know? She shot him, stabbed him, hit him with a frying pan, slept with his best friend…I was at a point where I was going to hit my mom, or leave. So I was like, I can’t hit my mom…she’ll probably beat the shit out of me – she already has – so I fucking bailed.
Aspen, like Hudson, discusses choice as a decision between remaining in a perilous situation or choosing the alternative despite looming uncertainty.
Respondents residing in an institutional setting prior to becoming homeless emphasized how their being homeless provided them with independence and freedom. Governmental regulations restricted their flexibility to move around prior to being 18 years old. Being under institutional care was perceived as being trapped. Jake, a 20-year-old male, illustrates this point when reflecting on his group home experience. Initially placed in foster care at the age of ten due to a history of abuse by a step parent, Jake was later moved to a group home. He recounts his move to group homes by describing how he was unaware of the situation in which he would be placed. Consequently Jake chose to leave.
Yeah, well…actually I was tricked into a group home. My foster care case worker…you know, I’ve never heard of a group home, never seen one at that time…and he was making group homes look like Club Med, and everything…and threw me into the group home. And then from there…that’s where it became a continuous thing. I was a big awol-er when I found out how bad group homes could be…I’d never…umm, never knew about these group home things…and how closed in they are, how structured they were…I didn’t know any of that. I was used to playing around when I wanted to – like a kid. I was put into a group home, while I was going through my teenage years…and you want a whole lot of freedom.
Jake, like many other respondents who resided in either foster or group homes, escaped these institutional setting in the attempt to achieve autonomy. Becoming homeless was an opportunity to assert control over one’s actions and surroundings.
Perceived control and reasons for staying homeless. Another area in which the respondents referred to perceived control was when they described their desire to continue living on the streets. The most commonly cited reason for remaining homeless was a desire for an alternative lifestyle, often one distinct from the lifestyle in which they were raised. The traditional culture that most respondents were raised in was often referred to as the “9 to 5-er;” a lifestyle characterized by routine, structure, and working for the sake of accumulation of wealth. Twenty-four year-old Madison describes harboring spite toward the “9 to 5-er” mainstream society, and how that in turn, influenced his decision to live on the street. At twenty, Madison was kicked out his home by his parents, as a result of his substance use. His parents had offered him the option of moving back in, as well as paying for treatment. However, Madison, having somewhat curtailed his usage on his own, refused the offer, preferring to remain on the street. When asked what motivated him to continue living on the street, he replied:
Spite, a lot of it. Towards the self-righteous fuckin’ bastards. They’re like the cartoon people that society has created, that are like perfect, you know? They’re the image of what so-called suburbia and urban like life. [Like the 9 to 5-er people?] Yeah, yeah. That shit was like the American dream supposedly. Fuck all those people. I’m happy living life with a backpack, a blanket, dope, and some fucking good friends.
Similar reasons were heard from other respondents who declared living on the street was not only a form of rejection of the traditional culture, but an embracing of an alternative lifestyle. Sawyer, a 20-year-old who had been on the street since the age of 14, described components of the alternate lifestyle that he preferred, despite the norms associated with mainstream culture.
There’s no way you can look at someone, and be like, and try to understand that I’d rather eat out of the garbage. I’d rather live off the waste of the system, that’s not even waste. Perfectly good stuff that gets thrown out for no fuckin’ reason. I’d rather live off of that. Like, why not? It’s there, you know?”
Sawyer, like many other respondents, communicated that his decision to live on the street is a lifestyle choice – a way in which to control not only the immediate housing issue, but also a process of walking away from a culture he did not agree with.
Control and rationale for using substances. Perceived control also emerged as a prominent theme in respondents’ descriptions of their experiences around substance use. The use of substances was not described as a behavior to which youth fell victim as a result of their chosen lifestyle; respondents talked about their substance use in an assertive tone, similar to that heard in discussions about their path and reasons for remaining homeless. Two processes by which respondents asserted control in their substance use was via self-medication and escape.
Nearly one third of respondents communicated that they used substances to alleviate symptoms of self-reported illnesses or conditions such as depression, bipolar disorder, hyperactivity disorders, and schizophrenia. They described substance use as relieving three types of problems: manic-depression related swings, self-esteem issues, and hyperactivity associated with Attention Deficit Disorder/Attention Deficit Hyperactive Disorder (ADD/ADHD).
Though information was not available to ascertain whether these conditions were professionally or self-diagnosed, the perception of the problem seemed to motivate these homeless youth to use substances as a practice for resolving or compensating for their psychiatric condition. Respondents who self-identified as suffering from manic or bipolar disorder discussed experiencing phases of aggression followed by periods of depression. These high/low swings prompted many study participants to search for a ‘fix’ or something that would balance their extremes. These homeless youth discovered that the use of drugs available to them achieved a sought after mood stabilizer. As a result of having found a ‘solution’ to their mental health symptoms, study participants discussed a lack of concern about their substance use.
Chance, illustrates this point when describing his mood swings and motivation to use substances. Having been on the street since the age of 17, Chance, shared that he used substances as a way to deal with his manic or bipolar condition. For this 20-year-old methamphetamine and marijuana dealer, his bipolar condition often disrupted transactions of business and hustling. When asked specifically about his motivation to use, he responded:
I use cause I want to. I use crystal because I’m really an anti-social person…and I’m manic. So when I do crystal, it makes me kick it and be cool. Like when I’m not…I just don’t feel it…and I don’t trust people and shit. Like this [the street] forces you to interact, like all the time and shit. A bunch of people…and all that. Like right now, if I wasn’t doing dope, I’d be a really violent person. [Do you feel like it calms you down?] Yeah.
Chance’ words demonstrate that he chooses to use crystal methamphetamine for its ability to even out his swings of aggression and self-isolation. In this manner, Chance’ substance use allows him to become calm and stable so that he can interact within a perceived social environment.
A small number of respondents additionally conveyed using drugs in order to lift commonly associated symptoms of depression such as loneliness, low self-esteem, and suicide ideation. These respondents often used the phrase ‘it makes me feel better’ to describe the result they sought from using substances, most frequently heroin. Cane, a 23-year-old male, candidly recounted having used nearly every drug in order to compensate for a history of mental illness. At a certain point in the dialogue, he explained his reasons for continuing to use heroin:
Umm, my diagnosis was all over the place….but most recently schizophrenia, ADD, and manic depressive bipolar. There’s no happy with the last one…no happy. That’s why I do drugs; it takes some of the edge off, makes me feel normal. I feel like I could be a happy person if I wanted to be. Heroin actually gives me the option of being happy or not.
It is interesting to note that Cane, similar to the other respondents who described self-medicating to ‘feel better’, revealed a history of trauma and abuse at the hands of parental figures. These past experiences with trauma were seen as influencing feelings of despair and suicide; Cane perceived himself as using substance in order to ‘fix’ his misery or lift his spirits.
One additional respondent, Samantha, talked about being diagnosed with ADD/ADHD while young, and given Adderall® to help control her hyperactivity. Since becoming homeless, her physicians questioned the validity of her diagnosis and would not refill her prescription for Adderall®. Consequently, to control the hyperactivity herself, Samantha turned to methamphetamines to help her sleep and deal with her ADD/ADHD. She explained:
I was one of those ADHD kids during the Ritalin phase…and I had a prescription for it, for a little while…for Adderall. It was beyond 30-50 milligrams of Adderall a day…that is a lot of…but boy, if I didn’t have it…I never stopped moving, and never slept. When I was on the meds – I could do one thing at a time without getting stuck at it. And every single doctor since then has chosen to question me since then. I’d love to go back to Adderall…I can’t stand needles…but I cope….I mean, there were a few weeks where I needed to sleep…and I took a shot [of speed] to go to bed. I seriously really…speed slows me down…I don’t want my waters to be all rough and muddy…I just want smooth sailing.
In lieu of a prescription, Samantha chose to intravenously use methamphetamines, and control her hyperactivity. By using drugs that gave a similar effect as the Ritalin®, Sonora found a pace that she was comfortable self-initiating.
For other study participants, substance use provided a means to escape from their current reality. To contrast with the process of self-medication, respondents in this category discussed detaching from their situation, as opposed to ‘fixing’ it. They spoke of a willingness to escape to a different reality rather than face the one ahead of them. The majority of these participants articulated using substances as a way of coping with a particular issue in their life, such as a past trauma or loss of relationship. Hudson illustrated this point when talking about the impact of having just ended a serious three and a half year relationship:
…the drugs give you that like temporarily relief from your reality out here…it’s not as bad when you’re under the influence. Yeah… losing my girlfriend like did a number on me. I’m rather depressed about that…I think I’m using drugs and alcohol to suppress that. Suppress that feeling, you know?
The remaining respondents in this category discussed escapism as a method of avoiding thoughts of regrets about where they should be at that point in their lives and what they did not have as a result of their prior choices. Youth included in this study comprehended the reality of their situation, but were reluctant to process how they had gotten to that point. In lieu, these respondents chose to disengage from their current circumstances. Ember, a 21-year-old female, narrated the scenario surrounding her drug use.
I wasn’t happy with myself especially…I did not like where my life had been…and I was mad at myself. And I blamed myself…and got into drug use, to forget…something different than the way I felt then. I was tired of feeling that way…more and more depressed and then I did drugs…and then it all went away. Life just got perfect, for that moment in time. The rest of normal reality all just floated away. And we were in our little happy palace…and my palace kind of crumbled into me…so I made a new reality.
These comments are mirrored by her peers who demonstrated a high level of awareness of their situations, but chose to separate themselves from that reality, and create a new, and most times temporary, state of mind.
Control and trigger to change usage. Following the continuum of substance use, perceived control was also discussed as a trigger to change participants’ drug use. Nearly half of participants expressed that their desire to change their substance use was triggered by a loss of perceived control. For several respondents who communicated that they no longer had control over their substance use, they expressed that their substance of choice dictated their actions and thoughts instead of themselves. Ember, an individual who admitted to having problems with authority, valued the importance of being completely in charge of her life. Throughout multiple conversations, Ember talked about having the willpower to accomplish tasks for the sake of no one else, but herself. In this same vein, she discussed her experiences with heroin – recounting the difficulty she experienced when trying to quit.
“And it just…it hit me so hard that I was unable to stop doing the drug even at my own will…That’s what I have a problem with…things like that. I’ll even test myself sometimes – let’s see if I can have more control over me than the cigarettes for a couple of days. With the heroin, I wanted to stop doing it, but the drug wouldn’t let me…the drug had control over me, instead of me having control over myself…”
Ember went so far as to test her willpower to ensure that she had more control over her ‘self’ than the drug. When that willpower was compromised, Ember took the initiative to change her usage.
For several study participants, a desire to change their substance use pattern was motivated by a loss of control over one’s morals. These homeless youth verbalized turning into a person with whom they were not comfortable: someone who resorted to stealing in order to obtain money for their drug habit or who overstepped ethical boundaries they had set for themselves. Loss of morality was communicated as an ultimate ‘rock-bottom’ – a point that could not perceivably be surpassed. Coral talked about this rock-bottom when sharing her experiences with cocaine.
Well, I came to the realization that I hit rock bottom…scared the hell out of me. I had become this like scandalous, shady little like vampire who just wanted to get money, any way I could. Like I lost myself, and I realized that I was gone, you know?
For Coral, a loss of morals represented rock-bottom, a place which she refused to contemplate reaching. Having prioritized her sense of ‘self’ over cocaine, Coral sought to change in order to recover the personality she felt she had lost.
Other respondents similarly described this loss of morals as a catalyst for change. Wednesday, a 17-year-old female methamphetamine user described having a “wake-up call”, a point in time where she was able to articulate the consequences and toll that substance use took on her self-worth. In this quote, she identified certain personal standards that she ignored while using methamphetamines.
…it would turn me into someone I don’t want to be. Cause I used to tweak…and it made me slutty, and I don’t want to be that way. I’m a really loyal person, but I was too impulsive. People would tell me things, and I’d want to believe them so much – I wanted to believe they cared so much – that I would. I made it so that I couldn’t hold myself back. I had to change, I’m not that kind of person.
Overall, it is interesting to note that the individuals who expressed loss of control as a trigger were among some of the same respondents that articulated making a choice in their pathway to homelessness or lifestyle. In effect, the same perceived control that was sought after in gravitating toward street life influenced respondents to abandon their substance use when diminished. This point will be further discussed later in the paper, in relation to barriers these respondents face when attempting to change their substance use patterns.
Element of Change
At the time of interview, youth included in this study were divided when discussing their perceptions of change. Half of respondents expressed readiness to change their substance use pattern, while the remaining half expressed being content with their current level of usage. Perceptions of use widely varied between the two groups, reflected in respondents’ rationales behind perceptions of change. Participants who expressed trepidation over their current pattern of use will be discussed first, followed by those who were less concerned about their level of substance use.
Desire and readiness to change. Respondents who described a desire to change talked about their current usage with feelings of resignation and exhaustion, with phrases such as “I hate the continual daily use”, “I’m getting tired of it”, or “I either stop now or die.” Nikki, a 23-year-old female, had been using heroin intravenously for four years, and probably acquired Hepatitis C due to her practice of sharing needles. When asked whether she perceived change with her heroin use in the near future, she communicated, “Like it can’t go on like this…I don’t really like it right now, and I think after this, I’m just gonna try and avoid it. There’s this point where it’s not worth it – just happens.” Nikki, like many other study participants, discussed reaching a point at which her substance use would overtake other prioritizations in her life. Though unable to articulate what this point would be, she mentions reaching that it would ultimately motivate her to make a change in her drug use.
Factors which resulted in reaching this point of change were coded as triggers and were not the same for all study participants. Respondents’ triggers included loss of health, loss of self-control, and environmental changes. The most frequently mentioned triggers, however, were the perceived loss of support that would occur if their substance use continued as well as potential jeopardy of future ambitions. Related to loss of support, respondents discussed their fear of losing friends, relationship partners, or family members if they decided to continue on their current path. As a result, social support was influential in participants’ decision to change their substance use patterns.
Briar, an 18-year old young woman, grew up in a continually changing environment. Briar was mainly under the care of her grandmother due to her father’s incarceration until her 12th birthday. Similarly, Briar’s mother, having separated from Briar’s father ten years prior, returned to meet Briar at the age of 14. As a result of perceived instability, Briar left home with her fiancé, at the age of 15, and chose to become homeless. Two years later, while living on the street, her fiancé and best friend were killed in a car wreck; Briar recounted experimenting with heroin to avoid dealing with the trauma. At the time of the interview, Briar had become involved with a different individual and was contemplating the consequences of her continued drug use in the context of her relationship.
I really want him to be my best friend in sickness, and health, and forever and ever. Whether or not we do dope or not. He doesn’t…he doesn’t like it anyway…doesn’t want anything to do with it…makes me not want to do it…I’m thinking about it cause I don’t need drugs when I’m with him, you know?
Coming from an upbringing filled with instability and a lack of social support, Briar’s boyfriend plays a pivotal role in influencing her to consider changing her substance use.
Among those that expressed the desire to change as a result of a possible loss of support, it is significant to note that their upbringings mirror Briar’s. Though all spent some amount of time in a home setting, these respondents can all be characterized as having grown up with ‘non-traditional’ parental figures: being raised by grandparents, uncles, substance using parents, step or adopted parents. However, it is at the influence of different, non-parental/guardian, supportive individuals that these respondents express their desire to change. Having had no social support network growing up respondents were positively impacted by a form of support introduced later in life.
The presence of future ambitions was also a trigger to change that emerged among those respondents who expressed dissatisfaction with their substance use levels. When asked about where they saw themselves in the near future or where their path might lead them, study participants described ‘reintegration goals’. These reintegration or long-term goals included going to school in order to reach a certain career, or purchasing property upon which to settle down. Furthermore, they discussed reaching these goals in a step-by-step fashion, identifying long term goals, and the more immediate task of changing their substance use in order to reach the larger goal.
Pax, a self-admitted alcoholic and marijuana addict, demonstrates this point in discussing her current circumstances and the changes needed to achieve her goals. Having dropped out of her first year of college, she spoke about ultimately wanting to go back to school, but also having to make necessary sacrifices to attain that goal. “I know that if I want to go back and maintain a job, I’m gonna have to cut down – I want to learn…and finish college, you know? I can’t do that if the drugs are in the way.” This quote illustrates Pax’s ability to place her substance use in the larger context of her goals. By outlining the steps required to enact this change, she better prepares herself to reach her goal.
Rationale and unwillingness to change. Respondents who were not motivated to augment their current substance use levels described their perception of personal substance use with a sense of contentedness. Study participants justified their unwillingness to change in a multitude of ways: articulating a certain control level over their usage, believing their substance of choice is not harmful, or declaring that their substance use was phase-related.
Several of the youth included in this study expressed not only the desire to continue their current usage, but that their current use was under control. These respondents frequently mentioned the concept of moderation, describing having attained a middle ground. Study participants recounted having previously gone through an initial high and low in order to find this middle ground. Furthermore, they emphasized the point that they were not addicted, and had the ability of stopping at will. These cessation scenarios, as they were coded, revealed participants who self-initiated curtailing their usage to a level with which they were more comfortable. Pierce, a 20-year-old male, having grown up on the streets since the age of 14, narrated a life history which consisted of multiple periods of both voluntary and involuntary interventions intertwined with traumatic and life-altering events. One such period, in Pierce’ life, involved being young and experimenting not only with different drugs, but testing personal limits and rebelling against externally defined limits. Pierce described his thoughts about his first run – living in a big city with his best friend, and the drug use that accompanied.
There’s no way I can explain the crazy shit me and him were involved in…and got into. We were kinda like untouchable. Being young and drugs, but young is most of it. It’s just…life ain’t like that for me anymore. The first run, you’re doing all this crazy shit…whatever it might be, and you’re not thinking. But like once I went to jail and decided not to do drugs – when I did do them again, it was never the same.
Pierce depicted this first run with the idea that he had hit his ultimate out-of-control high, and despite how hard he tried, he would never reach that point again. Though his time in jail and court-sentenced treatment was self-admittedly influential, Pierce communicated that it would not keep him from ever using again. In the following quote, Pierce discussed that since having arrived in Berkeley, he had begun using heroin again.
I started using drugs recreationally in this last year, and I don’t know how I feel…like I’m not disappointed – I knew someday I’d do dope again. I never fucking said that I’d never do it again. You know, I don’t think it’s all black and white…I don’t think I’m all fucked…every once in a while I crave the fucking dope…and then I do it…but I’m not worried, this is under control.
Pierce explains that after having gone through a phase where he peaked, and then had gone through a period of cessation, his current pattern was not of concern. This example demonstrates the capability of control that many of these homeless youth perceived over their substance use, instilling them with the confidence that, if desired they could curtail their own usage.
Several study participants also believed that their substance use was not harmful. They spoke unabashedly about the fact that they enjoyed using and had no interest in curtailing the amount they used. Analysis revealed that this group was characterized by the fact that they all smoked marijuana. Furthermore, some of these respondents mentioned that marijuana was used by many people in their lives including friends, partners, and family members. Sly, a 22-year-old male explained this point in justifying why he doesn’t intend to quit his substance use. “Yeah, my daddy smoked weed, my uncle and auntie smokes weed, my grandma smokes weed. I’m never gonna stop smoking. Doesn’t bother me, everyone around me smokes…” Sly illustrates his lack of concern over his drug use, which stemmed from the wide integration of substance use within members of his family.
In addition, a few respondents talked about their substance use in the context of phases. These participants identified that their substance use was related to a partying lifestyle they were unwilling to relinquish. When asked whether they perceived a change in his substance use at a point in time, one young man, Boxx, verbalized, “Oh yeah, I’m sure they’ll be a point where I’ll grow out of it. Between here and then, though, I’m not ready to give things up…to give partying up.” Boxx conveyed that his substance use and associated lifestyle was not something that would last forever. As a result, Boxx was not concerned about his substance use due to its phase associated nature.
Youth included in this study who expressed little alarm with their levels of substance use described two factors that encouraged them to continue in their use: social support and future ambitions. These enabling factors were the same factors that motivated ‘concerned’ study participants to change. Similar to those participants discussed above, this cluster of sampled youth experienced a lack of social support while growing up. However, many respondents spoke about having the presence of an individual from whom they perceived support. Often, this support came as a result of being in a relationship. Notable is the fact that their partners were substance users themselves.
Wednesday described home life as ‘tortuous’ and ‘unpleasant.’ She often recounted that her parents were restrictive and disapproved of her lifestyle choices and behaviors. As a result, Wednesday felt disconnected from her family and sought support elsewhere. However, upon becoming involved with her boyfriend, both a drug user and dealer, Wednesday began using methamphetamines. Shortly thereafter, Wednesday’s parents admitted her to a treatment facility, effectively removing her from her support system. At the time of the interview, Wednesday had escaped from her treatment facility in order to spend time with her boyfriend. In this quote, she described her sense of commitment to her boyfriend. “I wanted to spend more time with my boyfriend, so I left drug rehab. I’ve never had a friend or anyone close, and Cane was the closest person I’ve ever had to a friend.” From this quote, and throughout the course of the conversation, Wednesday reveals that she has never felt closeness with anyone until Cane, regardless of her many attempts at reaching out to people. When asked whether she started using drugs due to his own drug use, she casually responded, “Yeah, but I would have started using it anyway. At least now, I don’t have to go through other people…if he’s not going to quit, I have a lot of years to make up for. It’s like whatever happens to him, I want to happen to me…” Though Wednesday expressed the possibility of her using regardless of having met her boyfriend, it is at the influence of having a boyfriend who both deals and uses that Wednesday actually began and continued her usage. In this manner, Wednesday’s current peer support from her boyfriend in turn supports her substance use, both in commencing and enabling further use.
An additional enabling factor identified by study participants was future ambitions. Unlike those who desired change with their substance use, these respondents described being enabled by the lack of future ambitions. They discussed either subsistence, or short-term goals, or were unable to articulate future goals. Subsistence oriented goals revolved around finding a place to sleep that evening, or obtaining a temporary job for the purpose of fulfilling survival needs. Those who were unable to identify future plans described sentiments of being satisfied with their current circumstances and lifestyle, hence not perceiving the need for change. Sawyer, an individual who had spent six years on the street, spoke of very few pressing needs that he wanted to fulfill; he was living the life he had always wanted.
There’s nothing I can perceive wanting to do right now that’s gonna take a lot of my time. I can’t see any of my long term goals being that difficult to achieve. I don’t really have a lot of long term goals, though. And…ever since I met those traveling kids, since I was 13 or 14…I wanted to travel and ride freight trains, and stuff. And I did it. And I’m doing it. So, can’t complain.
In effect, Sawyer’s goals, or lack thereof, did not encourage him to change his behavior or surroundings. Without a tangible goal to work towards, Sawyer felt complacent in his current state of being. An intravenous heroin user, Sawyer frequently talked about how his usage depended on the availability and quality of the heroin in each place he had visited. In this manner, he stated that his perception of his usage focused on the immediate future. He talked about his current use of heroin, “Mmm, I don’t see it as a problem right now. I waste a lot of time on it, but I mean, I have nothing else to do.” From this perspective, Sawyer discussed that his usage was not problematic due to the fact that he has no other plans that require his attention or time. In this example, Sawyer implied that he has no reason to change his substance use pattern because he has nothing foreseeable to work towards.
Barriers to change. Irrespective of expressing a desire to change, all respondents were probed to identify what barriers stood between them and the process of considering and/or implementing change. Respondents who had begun contemplating a change in their substance use discussed barriers that prevented them from actualizing their intentions. Barriers impeding these respondents’ from changing came in many forms, but could easily be divided into personal and external barriers. Personal barriers included respondents’ lack of motivation, self control, and pride. Respondents who identified personal or internal factors described wanting to change their usage but not having the motivation to follow through. Ember insightfully commented on this issue, speaking about situations she had seen others face. “It’s like people get stuck, and they get sucked in. The drugs are there, and they’re sometimes easier than getting out of town to get clean. Sometimes getting out is harder.” Other respondents spoke about these internal barriers – describing feeling embarrassed to ask for help from family members due to past incidents of betrayal and deception in the course of their substance use.
Aiden, a 21-year-old male, grew up with parents whom he later discovered were not his birth parents. In reaction, Aiden rebelled and ran away. Caught, Aiden was placed in foster care and then a variety of group homes. In interviews, he said that since reaching the age of 18, his parents have constantly reached out to him and offered to pay for any rehab services he might need. Aiden shared his hesitation in accepting their help.
All they do is let me in the house to get clean, do right. And I do fucked up things to them, I steal from them (crying). That’s part of the reason I don’t want to be there and take more help from them – cause I can’t look them in the eyes…
Aiden verbalizes the difficulty in facing his guilt and shame with those closest. Although declaring the desire to move forward towards a stated intention, Aiden and others illustrate that the process of change presents many internal facets to overcome in order to actually implement a difference.
External barriers identified by the remaining respondents concentrated on being unable to financially support themselves if they were to truly change their lifestyle and substance use pattern. For these respondents, ceasing their substance use required a complete dissociation from the environment in which they used and conducted business. This lack of sustainability was problematic and was viewed as a barrier for some of the respondents who revealed a desire to change their substance use.
Donner, a 20-year-old male, was taken from his mother and separated from his sibling, at the age of ten, due to his mother’s mental instability and substance use. Since the age of ten, Donner bounced between foster care, group homes, boot camps, and juvenile hall. Upon being released at 18 from institutional care, Donner began hustling and stealing to survive. Describing this scene, he explained “I hate the drug scene – I need out. I can make a lot of money off of it; it’s just that I got rocked up in it real bad. I’m just like fuckin’ running circles…like Alice in Wonderland. It’s awful.” Having verbalized a desire to change was not enough in Donner’s case. Attempting to get a job after his last period in juvenile hall, Donner was turned down, interview after interview. He realized that he had not gained any skills or experience that would help him in obtaining a legitimate job. He explained:
It’s like I gotta plan and I gotta get out of here…but I ain’t never had no office job, cash register or waiter job, none of that shit. I was too young – and if I wasn’t locked up all the time, I’d be on the run, and you can’t get no job on the run.”
Donner demonstrates that regardless of his plans and goals to make a change in his life, he has no economic assurance that it will work out. For Donner, taking this leap to change his substance use cannot sustain itself if he cannot remove himself from the scene where he has previously supported himself.
Among those who did not perceive a problem with their substance use, internal barriers and external barriers were not as easily distinguishable. A deficiency in self-motivation was linked to the need for an external advocate. Barriers to change predominantly clustered around a lack of support or community that would support respondents’ efforts to get clean, when and if they were ready to do so. For some respondents, this supportive individual took the appearance of an advocate that could motivate the respondents through the process of changing their habits. Yet for others, it was simply an encouraging friend who could reinforce sentiments of self-worth. Penny grew up with a mother who had been homeless and abused drugs since Penny’s birth. Penny commented on barriers that existed for her mom before change was even a process to consider.
My mom had no one out there to give her a hand…she’d been out there doing that shit for so long, that’s where she was going. If she had had someone that was like….’you can like do all this shit, straighten out your life…you can be somebody, you know?’ Nobody ever showed her that, you know?
Penny illustrates that though her mother never expressed a desire to change, the lack of support she experienced prevented her from reaching a trigger point. Revisiting the fact that Penny and her peers integrated their current support system with substance users, change – when and if ready – involved the effort of either removing oneself from their current support system (and risking being in a situation like Penny’s mother) or influencing two individuals to change together. Realizing the difficulties belying either of these options, change becomes an intricate process that often begins and is influenced far in advance of a declaration of intention.
Future of Treatment
On the topic of substance abuse treatment, each research participant predominantly critiqued the current treatment program model. In other words, respondents identified substance abuse treatment needs unique to their population which were unmet in the context of the current treatment model. Controlling for personal experiences with treatment, the specific areas of inadequacy mentioned did not differ: flexibility, stability, experienced staff, and a sense of community.
Flexibility. Participants, who highlighted the necessity of flexibility, discussed fears of losing their freedom when entering treatment programs. These research participants explained that both themselves, and peers, were accustomed to a certain sense of independence while living on the streets. Therefore, restriction on this independence in order to participate in treatment was viewed with reluctance in some cases and with complete objection in others. Respondents addressed this concern by articulating that if treatment programs wanted to retain youth like them, their emphasis should be on flexibility. Chance, a poly-drug user, had lived his entire life on the streets of Berkeley and Oakland. Having never known the whereabouts of his family, he grew up solely in foster care and group homes. In discussing what would be useful in his process to curtail his substance use, he describes his needs as such, “I need somewhere I can be in and out, you feel me? Where I can just kick it…I can’t be on lock down, it’s totally – I hate it. If that’s how it is– it ain’t worth it, nobody’s gonna go.” Chance conveys that if treatment programs restricted his freedom to come and go neither he, nor his peers, would be interested in attending.
Other research participants’ related flexibility to the efficacy of treatment programs. These participants described treatment programs suffering from a black and white mentality – unwilling to accommodate differing perspectives and viewpoints on the continuum of substance use. These respondents conveyed that treatment programs seemed averse to yield from their agenda and treat clients on a case by case basis. Ember illustrated this phenomenon when recounting her past treatment experience, “I didn’t like it in there cause instead of getting to know each person, and understanding who they are, and what needs to be done, they just…If it’s not in the books – that’s not the way it is, and that didn’t seem right to me.” In effect, Ember discussed feeling as if she was being made to fit into a mold in which she did not necessarily belong. This sentiment of being pigeon-holed also spoke of her reluctance of having others making decisions on her behalf. She continued in her description of past treatment programs in mentioning the following:
I’d tell them this was the way I think, and they’d be like, ‘No, that’s not right. That’s not right.’ And I can’t….me personally, I have a bad reaction to authority….being told what to do…being told that the way that I’m thinking is wrong.
Ember articulated that in entering treatment, she was not permitted to express independent thoughts. This relinquishing of self proved problematic when she ultimately ran from the program within two weeks
Another participant, Pierce, had had numerous experiences in treatment, both voluntarily and via court-order. From those experiences, Pierce came to a conclusion that many treatment programs for youth, instead of being invested in helping youth to solve their problems, mainly sought to remove delinquent youth from their surroundings. Building on these beliefs, the following quote recounts his most recent treatment exposure and his lack of engagement when discovering that this program mirrored his past experiences.
I bullshitted my way through that thing – got me out faster. It was some douche bag that supposedly knew what the fuck was up – it sucked. It was just all black and white. It’s not thinking about how life actually is. They don’t get it, and I’d rather do it alone.
Pierce illustrates the impact of an all or nothing approach to treatment; he would rather attempt to curtail at his own peril, rather than return to a treatment program. This perception of treatment effectiveness, as a result of his experiences, encouraged Pierce to avoid formalized treatment – then and in the future.
Pierce goes on to explain that flexibility was also important, in the context of treatment, due to temptations of life on the street. He touched upon the necessity of treatment programs considering the possibility of relapse among homeless youth. He articulates:
I think it’d be helpful if there was a place that I could just go, and if I were to use, I wouldn’t be completely fucked out of it. Cause some kids get into the mode of quitting, and someone offers them a way back into the drug world. And sometimes it’s too much – the stress of this lifestyle, of being homeless, of being hooked on drugs – they have to try a few times, before they get it.
Pierce identifies the stressors in many of his peers’ lives that emerge as barriers to sustain, or remain in treatment programs. He expresses that it is with consideration of such factors that treatment programs should exist.
Stability. Some participants discussed the need for stability in treatment programs. These respondents communicated that the stressors associated with being homeless was not conducive to kicking a habit. Such stressors, for many of the participants, included daily uncertainty in sleeping locations, accessing meals, and obtaining money to buy their substance of choice. In this way, respondents spoke about how stability, in the context of a treatment facility, permitted them the space (both mental and physical) to address their problems with substance abuse. Hudson, a 24-year-old youth who has been homeless for seven years, talked about his difficulty in cutting back on his ecstasy and methamphetamine use. He attributes this partially to being worried about his next meal or being woken by the police at his squat, a place of sleep. Considering making a change and admitting himself to a treatment program, he describes the importance of stability in battling his substance abuse. He explains, “Actually, I been thinking about administering myself to a drug rehab program – a program that could be a temporary from not being homeless. A little bit of stability and maybe I can get my head together there and quit this.” Hudson describes the role treatment can assume in providing a refuge from the transient and often, chaotic, aspects of his lifestyle. For him, it is this sense of stability that could allow him to overcome his substance abuse problem.
Experienced staff. An additional few research participants talked about the integral role that staff played in the treatment process. Participants described staff as the group of individuals who were responsible for the treatment center’s day-to-day operations. Due to their prolonged contact with clients, staff was viewed to embody the main purpose and mission of the treatment center. For participants, the center’s mission was best served by staff that had had similar experiences with homelessness and substance abuse. Respondents explained that ‘experienced’ staff would not only lend credibility to the treatment program for youth like themselves, but also create connection to staff members who would be able to see things from their perspective. Cruise, a 23-year-old male who left home at the age of 17, spoke about the utility of treatment for homeless youth, but he was reluctant to admit himself to a program due to friends’ experiences with staff members. He explains:
…the people that work in most of those places are there for their paycheck. They don’t really care. They’ve never been homeless. Like…see, I’m homeless. I’ve been homeless for a long time. And I don’t and really won’t connect with people who are trying to get me, and all that…because they don’t know where I’m coming from, what I’ve been through. That’s what matters.
Cruise articulates that staff who have had similar backgrounds and experiences have a certain investment in helping others whose situation was once familiar. His admittance into treatment and curtailing his use within a treatment facility is contingent upon such experienced staff.
Community. Research participants mentioned the necessity of having a community inside the walls of the treatment center. Many of these participants described that their pathway to reaching a point of change would involve detaching from their current, and often substance using, community. By admitting themselves to a treatment center, these participants were leaving a support system or tangible community. As a result, research participants described the relevance and significance of a youth-oriented treatment center. Similar to advantages of interacting with experienced staff, having a community within the facility seemed to provide a sense of camaraderie and support during a difficult process. Fern, a 19-year-old female, articulates the importance of such encouragement and support among peers.
…because that’s about the level of comfort…that’s about you feeling like you can look to your left and look to your right, and you’re like, ‘Damn, my homie is sitting right over there.’ Maybe someone I know, maybe not…but like that cat looks like he’s been through what I’ve been through, and he’s like about my age…He’s got the courage to do this, then so do I, know what I’m saying?
Fern conveys that it wasn’t the impact of the relationship formed with the peer, but the simple presence of peers, from a similar background, that would motivate her to continue in her struggle against substance abuse.
It is interesting to reiterate that youth, regardless of direct experience with treatment, agreed upon the same needs for themselves and their peers. Findings showed, however, that differences due to prior exposure impacted attitudes toward ultimate utility of treatment services. Exactly half of respondents had had no prior experience with substance abuse treatment services. These respondents described treatment as being a helpful process to curtail their use. They spoke about being open to voluntarily admitting themselves into such a program if the need arose. The remaining half of respondents described substance use treatment as a pointless and non-helpful process to curtail substance use. These respondents could be categorized as having had prior exposure to treatment programs and recounted personal or family/friends’ unsatisfactory experiences in treatment. For the majority, one experience sufficed to discourage them from accessing future treatment programs.
Discussion
Conclusions
The objective of this study was to gain insight into homeless youths’ trajectory and courses of homelessness and substance use. By exploring the life histories of homeless youths, this study addressed a gap in existing literature, in order to determine appropriate intervention and treatment needs for homeless youth and to better inform service providers of homeless youths’ need and readiness for services.
The most prevailing theme throughout these homeless youths’ narratives was the concept of perceived control. Control permeated interviews in relation to how the participant became homeless, continued to be homeless, and the various stages along their continuum of substance use. Findings from this study revealed that street youths’ upbringings were similar to those of other studies with homeless youth: families characterized by discord between parents and/or between parent and child, neglect, substance use problems, and physical and sexual abuse (Whitbeck & Simons, 1990; Kipke et al., 1997b). In these cases, departure may have represented an act of personal protection, both for one’s physical and emotional health. Furthermore, perceiving a lack of control over their upbringing, and without access to social, emotional and developmental support, participants’ viewed their transition to the street as opportunities to assert control, where they previously had none. Though perhaps not a choice between desirable outcomes, these street youth appeared to attach a sense of ownership over their departure. This ownership, or empowerment, could have also allowed for participants to cope with their rapid transition from a situation of governed care to being fully responsible for their own well being. As a result of having catapulted into adulthood, relying on no one else but themselves, these homeless youth appeared to gain a sense of independence and agency (Hyde, 2005; Rew, 2003). This insight challenges the commonly held view of the homeless youth as a victim, acknowledging the youth as an autonomous individual who has had to assume the role of the sole caretaker in their own well being.
Research suggests that some of the same factors that motivate youth to run away such as family discord and physical and emotional abuse may also play a role in their rationale to use substances (Greene, Ennett, & Ringwalt, 1997). The literature fails to identify the role that perceived control plays in youths’ initiation and continuance of substance use. The present study’s findings reflect that a number of youths’ rationale to use substances was to achieve control over psychiatric and psychosocial issues. These results become more relevant in light of the documented high prevalence of mental health problems among homeless youth, including reports of depression, ADHD, self-esteem, and suicide ideation (Unger, Kipke, Simon, Montgomery, & Johnson, 1997), as well as the small proportion of youth who report accessing psychological services (De Rosa et al., 1999). Homeless youth not only had fewer mental health diagnoses, but even among those who were diagnosed, failed to access mental health services due to issues such as accessibility, availability, and concerns over confidentiality. These results suggest that many respondents attempted to independently relieve and control mental health needs which were most likely unmet. This point speaks to the structural constraints that often prevent homeless youth from addressing their mental health needs.
Additional findings illustrate the ability of many participants to curtail or quit their substance use at the loss of perceived self-control. These results are consistent with previous research showing self-control to be protective against substance use (Sussman, McCuller, & Dent, 2003). Respondents seemed aware of their personal limit, identifying a point at which they were no longer willing to maintain their substance use pattern. As a result, they independently sought to reduce or cease using substances, thus regulating their own behavior. These findings imply that respondents were able to recognize their comfort level as it related to personal behavior, as well as exert self-care, described by Orem (2001) as the ability to take action to regulate one’s own functioning and development. Having possessed self-reliance in the context of their upbringings, perhaps it is at the risk of losing perceived control that influences these youth to engage in self-care, abandoning their self destructive behaviors. These findings suggest that future interventions should support the decision-making ability of homeless youth, as well as recognize the role it has played within this population’s lives.
Social support was found to be an integral component of participants’ desire to change their substance use. In this manner, social support motivated some participants to curtail their substance use while enabling others to continue. Regardless of direction of change, the street youth included in this study grew up in similar environments consisting of poor or non-existent role models. Not unlike the upbringings of sampled populations described in the street youth literature, research participants described rapidly investing and attaching to peers, perceiving support from these resulting friendships or relationships (Bao, Hoyt, Whitbeck, 2000). Notably, for those that expressed a desire to change, this support system consisted of an individual who did not use drugs; for those that were not interested in changing their substance use, a substance using partner assumed the supportive peer role. Thus it seems important to note that many of these homeless youth reported loss of community as a barrier to changing their substance use due to an underlying fear of losing the only community or support network to which many of these street youth belong.
The findings from this study also highlighted the need to re-examine current treatment models and the theories which drive treatment facilities’ policies. Many respondents appeared ready to change their substance using behaviors, but unwilling to enter treatment as it presently existed. In this manner, participants described current treatment models entailing a process of ‘getting with the program’ often representing an inflexible perspective of achievable treatment goals, predominantly that of permanent abstinence. This inflexibility, however, was problematic for the homeless youth who sought to change their substance using behavior to achieve goals that differed from that of the treatment center. These goals, reflected in the literature on general substance users, often included cutting back temporarily to regain self control, to take rest from an addictive lifestyle, or to address an external pressure such as incarceration, familial relationships, or employment (Battjes, Onken, & Delany, 1999). Recognizing this variance, findings suggest that participants were unwilling to enter the current treatment model that did not permit them to set the pace and extent at which they worked toward their own goals; they appeared averse to relinquish control over the terms by which they changed their substance using behaviors. Implications of this finding demonstrate that treatment models seeking to engage and retain homeless youth should consider the facets surrounding readiness to change substance using behaviors by permitting flexible treatment goals.
The literature also suggests that substance users who seemed ready to enter treatment were not necessarily ready to change their substance using behaviors (Battjes, Onken, & Delany, 1999). In this manner, the findings illustrated homeless youths’ motivation toward treatment centered in their need for stability to address the stressors accompanying their lifestyle. These stressors included securing survival needs such as shelter, food, and their substance of choice. In addition, participants alluded to the chaotic environment within which they felt unable to tackle personal problems. These results illustrate the value of general support services and suggest that treatment programs focused solely on reducing substance use may fail to address these homeless youths’ co-existing psychosocial problems (Paradise & Cauce, 2003). Moreover, many participants reported using substances to cope with psychosocial and psychiatric problems, which imply that treatment models may better serve these homeless youth by equipping them with non-substance using strategies to deal with their stressors.
Participants also discussed the significance of having similarly experienced individuals surround and participate in their treatment process. These individuals included staff members at the treatment facility, as well as other clients enrolled in the program. These homeless youth expressed having more respect for those who could understand where they were coming from as well as the difficulties in the challenges ahead. This is in line with previous research on adolescent substance abuse treatment centers that emphasizes drawing from the experiences of other participants, as part of group therapy (Reisinger, 2001). Reisinger (2001) also reports that adolescents felt judged and ostracized if they did not feel others in the group understood their background and pathway to their current state. Implications of this research suggest that youth appeared to give more credence to treatment programs which staffed formerly homeless individuals, as well as those programs which were geared specifically for their population. Further in designing treatment services, research has shown that the current model effectively removes youth from their environment, breaking the support network upon which many of these homeless youth depended (Paradise & Cauce, 2003). Recognizing the impact of social support on these homeless youths’ decision making process, treatment models provide a perfect setting to develop and sustain new non-substance using support systems.
Limitations
Findings from this study should be considered in light of a number of limitations. First, findings relied on participants’ self-reports and may have been affected by reporting bias. It is possible that youth face to face with the interviewer altered the extent and perception of homelessness and substance use due to the stigmatized nature of both. Similarly, because interviews were conducted by a non-homeless individual, respondents may have responded differently than had the interviewer been of similar background and experience. Second, sampling methods were restricted to youth who either spent time on one of two popularized avenues or accessed services in the general vicinity of these two avenues. Thus, this sample of street youth may be biased by this selection process, and unrepresentative of homeless youth in other part of Berkeley. Berkeley is a magnet for homeless youth, and so it is possible that this sample is not generalizable to street youth populations in other cities. Youth who come to this area may interact differently with other homeless youth, possibly influencing substance use patterns (Unger et al., 1997). Lastly, due to financial and time constraints of the research study, intercoder reliability was not assessed, impacting validity of results relative to the singular coder.
Implications
The public health implications of this study are numerous commencing with the aging of this substance using homeless youth population. As these youth age into untreated substance using homeless adults, they become harder to access and treat due to their extent of substance use as well as their length of time on the street. Furthermore, in lieu of effective intervention and treatment services, the proportion of homeless youth, who could either begin or continue to use drugs intravenously, increases impacting the likelihood of obtaining blood-borne pathogen infections such as Hepatitis C and HIV.
Specific to the treatment model, these findings imply that homeless youth are not likely to engage or remain in programs where they feel a lack of control over the terms of their treatment or that their actions are being judged. In this way, the treatment model should reflect the significant role that both perceived control and support play in these homeless youths’ lives by incorporating flexible treatment goals which do not dictate the extent and manner in which they change their behaviors. Further, it is to the benefit of treatment programs to be programmatically responsive to these homeless youths’ needs, including the need for general support services. Though not directly addressing substance abuse, these services should provide homeless youth safety, support, stability, and skills with which to accomplish change in substance use if and when they are ready.
Recommendations for Future Research
The lack of research regarding substance-using homeless youth populations prevents the development of relevant and appropriate intervention and treatment. Without knowledge of this population’s perceptions, attitudes, and beliefs regarding their own substance use, ineffective and underutilized services will continue to exist, impacting not only the homeless youth themselves, but the political, economic, and cultural systems which attempt to solve the problem. Recognizing that within the city of Berkeley resources are limited to address the comprehensive needs of these homeless youth, further qualitative research should be emphasized and conducted with these youth to allow for not only appropriate allocation of resources but more knowledgeable and understanding service providers. This knowledge can then, in turn, permit for advocacy for social change that does not further marginalize these populations.
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Appendix A
Emory University
Department of Behavioral Sciences and Health Education
Informed Verbal Consent Script
Title: Substance Use Treatment Needs of Homeless Youth
Principal Investigator: Masuma Bahora
You are being asked to volunteer for a research project that is studying how homeless or street youth use health services available to them. The main researcher is a graduate student in the School of Public Health at Emory University. The purpose of this study is to understand the service needs among homeless youth who use substances. If you participate, you will contribute to the knowledge of substance use treatment of homeless youth, which could help create better services in the future. About 30 youth like yourself are being asked to participate in this study.
If you choose to participate in this study, you will be asked to respond to questions about the history of your homelessness and how you feel about available health services. The study will be a one-time, face-to-face interview that should last about around an hour. All interviews will take place at a location that will protect your privacy. Interviews will be tape recorded and reviewed only by myself. Tape recordings, transcriptions, and notes will be stored in locked file cabinet.
Participation is completely voluntary. I do not expect that choosing to do this interview will harm you physically or mentally. You may, however, be asked about certain issues in your life that you believe are too personal, or emotional to talk about. If you feel uncomfortable at any point during the interview, you may tell me that you want to skip questions or that you want to stop the interview. Your decision will not affect your treatment, now or in the future, by any health provider or clinic staff.
I will keep all facts and information that you give me about your experiences completely confidential. This means that the information you provide will be kept private and secure. To make sure your information is not shared with anyone, I will ask you to give me a pseudo name so that your real name will not be liked to any of the information collected. When this study is written up, your name and other facts that may point to you, will not be included.
If you have any questions about this study, please feel free to contact the principal investigator, Masuma Bahora, at (314) 369-4045. If you have any questions or concerns about your rights as a person who is part of this study, please call Dr. Karen Hegtvedt, Chair of the Social, Humanist and Behavioral Institutional Review Board, which oversees the protection of human research participants. She can be reached at (404) 727-5646.*
*A contact card will be provided with information on who to contact.
Appendix B
INTERVIEW GUIDE
Revised 7.16.05
• Tell me about how you became homeless? What was going on in your life at the time?
o Age you first remember leaving home/foster care/juv./being on the street?
o Where did you originally stay?
• What do you think are some of the best/worst parts of being on the street?
• What kind of interactions do you have with people that aren’t HL?
• Tell me about when you first started using drugs? For instance, how did it happen, how old were you? who were you with?
o What substance? Multiple?
o Before/After onset of HL?
• Tell me about how/if your drug habit has changed over time. What do you think is different in your life now, than then?
• What can you tell me about the drug(s) you use? What do they do for you? What are the consequences/effects?
• What are your attitudes about your drug use?
o Why do you continue?
o Something you see as changing in the near future?
• Why/why not?
• Where do you see yourself a little ways down the road?
• What are issues you might face in trying to change your drug use behavior (when & if you see that happening)?
o What would be necessary to help you change?
o What kinds of things make it difficult for you to kick the use?
o What kind of role do friends, lovers, family play in your drug use?
• Have you ever tried reducing or quitting your substance use?
o What happened?
o What worked/what didn’t?
o Who/what motivated you to change?
o In trying to reduce, did you have a goal you were trying to work toward?
• Would you ever consider entering treatment?
o Why/why not?
o What do you see as being positive/detrimental about entering tx?
o What do you know about available Tx options?
• Prior knowledge from experience or others?
• What would entering be dependent/contingent upon?
• In your eyes, what would ideal services or treatment center look like?
Appendix C
CODING TREE
2.8.06
I. PAST
a. Upbringing
i. Institutional Contact
1 Foster care
2 adoption
3 group homes
4 law enforcement – juvenile hall
ii. Abuse
1 neglect/abandon
2 sexual
3 physical
iii. Discord
1 b/w parents
a. divorce/separation
2 b/w child & parent
iv. Other
1 parental drug use
2 witness to death/suicide
b. Hx of HL
i. Choice
1 freedom
2 discord
3 boredom
ii. No choice
1 economic
2 escape
3 no place to go (phased out)
iii. Related to drugs
c. Description of Use
i. 1st time
1 age
2 knowledge
3 reasons
a. experiment/curiosity
b. rebellion
c. peer/friendship
d. community
e. functional (escape/relief)
f. self-medication
g. availability/access
d. Perceived Support
i. Present
1 Parents
2 Siblings
3 Friends
4 Partners
ii. Not present
II. PRESENT
a. Continued HL
i. Lifestyle choice
ii. No choice
b. Description of Current Use
i. Pattern
1 craving
2 binging
3 situational
4 habitual
5 stopped
a. how
b. periods of being clean
c. relapse
d. drug specific
ii. reasons
1 peer/friendship
2 community
3 functional
4 self-medication
5 addicted
6 financial dependence
7 boredom/apathy
iii. Repercussions
1 Psych
2 Physical
3 Social
4 Overdose
5 Comparing diff. drugs
6 Long-term effects
iv. route
1 snort
2 IV
3 inhale/smoke
4 ingest
5 reasons behind particular route
v. poly-drug use
1 drug & alcohol
2 drug & cigarettes
3 drug & drug
a. availability
b. self-medicate
c. experiment/curiosity
c. Classifications of Use
i. Perceptions of continued use
1 control
2 problematic
3 acceptable
ii. Perceptions of addiction
1 morally defined
2 quantitatively defined
d. Perceived Support
i. Present
1 Parents
2 Siblings
3 Friends
4 Partners
ii. Not present
e. Health Issues
i. Psych
1 hx
2 diagnosed
a. self
b. non-self
3 tx
a. self
b. non-self
4 result of use
ii. Physical
1 result of use
f. Triggers to change usage
i. Stigma
ii. Health
iii. Support
iv. Environmental changes
v. Goals/ambitions
vi. Loss of control/self-initiated
III. FUTURE
a. Barriers to change
i. Structural
1 jail
2 housing
3 lack of access
4 loss of community
5 economic
6 environment
ii. Personal
1 pride
2 support
3 motivation
4 fear of structure
b. Goals/Ambitions
i. Short
1 housing
2 usage
3 job
ii. Long
1 partner/relationships – repair
2 home
3 career
c. Perceptions of change
i. Want
ii. Don’t know how
iii. Know how
iv. Not ready
v. Tried
vi. Unsuccessful
d. Treatment
i. Attitudes about tx
ii. Prior exposure to tx programs
IV. Other
a. Death
b. Self-actualization
c. Advice
d. Rejection of ‘norm’ culture
e. Class Issues
f. Stigma/Stereotypes
g. ‘rock bottom’ experiences
h. structure
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