Few empirically supported treatments for street living youth are available. Many logistical, treatment and research barriers impede evaluation. For example, participant barriers include transportation and accessibility to the treatment research site, engagement, development of trust, and tracking for follow-up. Social barriers in treating youth include the provision of housing and psychiatric services for minors who refuse to have parents contacted or social service system involvement. In the current study, the Community Reinforcement Approach was evaluated and compared to treatment as usual through a homeless youth drop-in center.
Results showed that CRA is an efficacious intervention, as youth improved in many domains. As hypothesized, street living youth assigned to CRA showed statistically significant greater improvement in substance use, social stability and depression/internalizing problems compared to those assigned to TAU. Treatment findings did not differ depending upon age, gender or ethnicity with the exception that older youth assigned to TAU did not report reductions in BDI depression while younger youth reported improvement in depression. Possibly, older youth, who may have a longer history of homelessness and depressive symptoms, require a greater focus on coping, mood management, and others skills development as offered in CRA. Overall, many youth were engaged into treatment and responded positively to the intervention. This is significant in that engagement and maintenance of homeless youth in ongoing treatment efforts can be difficult (Smart & Ogborne, 1994
). Our findings suggest that an open door policy, engagement of youth slowly and without pressure through a drop-in center, and employing charismatic, informed therapists can contribute to effective engagement and maintenance of these youth in treatment.
In regard to clinical significance, youth who received CRA were improved but not recovered. For example, youth in CRA showed a 37% reduction in substance use (from 67% days use to 43% days use), while those receiving TAU showed a 17% reduction in substance use (60% to 50% days use). Given the reduction in BDI depression (40% v. 23%) and increase in social stability (58% v. 13%) among those in CRA relative to TAU, the potential for intervention and improving outcomes among these youth is promising. However, this study provides a very small step towards understanding the treatment needs and responses of these youth to treatment; much more treatment development research is needed to address the difficult life situation of these youth.
In summary, youth assigned to CRA showed greater improvement in some areas compared to TAU, but those receiving TAU also improved in several domains. All youth received assistance in meeting basic needs, and this could account for some of the observed improvements. Involvement of youth with a system in which adults provide positive, reinforcing experiences (received in both CRA and TAU) is likely integral to change. Both CRA and TAU provide youth with experiences consistent with the underlying theoretical assumptions of the developmental systems approach (Bronfenbrenner, 1979
). CRA and TAU provide one of the first times in the youth’s life that they are being reinforced for positive behavior. This fundamentally changes the youth’s relationship with a social system. The positive reinforcement for positive behavior places the homeless youth on a positive developmental trajectory that breaks negative interactional continuity and can be built upon, allowing for the possibility of further linkages to positive micro-systems. For example, if a youth requests assistance with obtaining a job and the therapist assists the youth in achieving this goal, the youth will see this as a positive linkage. The experience not only offers the opportunity of making the drop-in a part of the youth’s meso-system but increases the possibilities of the youth making similar linkages to other positive micro-systems such as one that offers medical assistance.
Thus, we believe that the Community Reinforcement Approach (CRA) therapy has the potential to impact homeless youth over the long term. This method of intervention attempts to change the relationship between homeless youth and their micro-systems and meso-systems. It is important to point out that the second intervention, the treatment as usual, also offers weak linkages to healthier settings. But because it is not focused on the larger ecological circumstances of the individual youth, this type of intervention is held hostage to influences in other parts of the youth’s meso-system. The TAU intervention’s effects are haphazard rather than purposeful and focused.
The research design is limited in that youth were only assessed at post-treatment. A longer follow-up is needed to determine stability of treatment effects. The design does not allow determination of whether CRA is more or less effective than other intervention approaches for treating substance abusing homeless youth. Also, all youth were recruited as a sample of convenience through a drop-in center. These youth might be more amenable to change, have greater trust or respond differently to treatment efforts than youth who do not access drop-in centers. Also, youth in other parts of the country who experience different stressors or community supports might respond differently to the treatment efforts examined in this project. The drop-in center from which youth were recruited was the only drop-in center designed to serve homeless youth in the state, and features of this center may have affected the findings. The drop-in center likely included activities, staff attributes and other features that were particular only to that drop-in center, and may not be representative of other drop-in centers. Since RA’s were not blinded to the treatment condition that youth were assigned, knowledge of the youth’s treatment condition may have affected the administration of the follow-up assessments and thus the data. However, without such blinding and assistance from the therapists or case managers in tracking youth, the follow-up rate would likely have suffered significantly. Moreover, youth were aware of the possible treatment conditions, and youth who were unhappy with their treatment condition may have biased the outcomes. Youth who did not complete each assessment interview reported significantly higher HIV risk behaviors and higher alcohol use frequency compared to those who completed each assessment interview. Thus, given that some of these higher risk youth were missed, the findings might over or underestimate the impact of CRA overall.
While development of psychosocial interventions is important, and much more research in this area is needed, substance use, health risks and associated mental health problems will likely continue until the youth is removed from the streets. Our goal in this treatment was to remove youth from the streets, but we were limited in achieving this goal. These youth, and especially minors, are unable to sign for housing without a guardian’s consent and refuse foster care. Older youth are often unable to acquire housing because of other barriers including financial, behavioral/emotional and social prejudice. It is difficult for youth to maintain housing and employment with an active drug addiction and mental health problem, and it is difficult for youth to address substance use and related problems without social stability. Future research will need to consider social barriers when designing and evaluating treatments for this population.