a program operated collectively by 19 medical specialty organizations, including the American Psychiatric Association. Please note that following today's presentation, you will receive a follow-up email within one hour of the webinar. The email will contain the instructions to claim your one-hour credit for attending. This activity offers continuing education credit for physicians, nurses, nurse practitioners, pharmacists, physician assistants, and social workers. Please feel free to submit your questions throughout the presentation by typing them into the question area, which is found on the attendee control panel. We'll reserve 10 to 15 minutes at the end of the presentation for question and answer. Next slide. And then, so the target audience for PCFS is to train healthcare professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications, as well as prevention and treatment of substance use disorders. Next slide. And now, I'm very, very excited to present to you the faculty for today's webinar, Dr. Natasha Sleznik. Dr. Sleznik is a professor of human development and family science in the Department of Human Sciences and EHE Associate Dean for Research and Administration. She's a licensed clinical psychologist, and her research focuses on intervention development and evaluation for substance-using youth who are experiencing homelessness and mothers and their children. She has consulted with multiple organizations on the best strategies for intervening in youth homelessness and adolescent substance use. She has been continuously funded by the NIH since 1998, and has written more than 100 peer-reviewed publications, book chapters, and books. After opening a drop-in center for homeless youth in Albuquerque, New Mexico, she moved to Columbus, Ohio, and opened her second drop-in center there. I welcome you, Dr. Sleznik, to today's session, and thank you for leading the webinar today. Well, thank you for having me. I'm so excited to be here, because I'm always grateful for the opportunity to be able to share some of the work that my team and I have been doing with youth experiencing homelessness. So this project that I'm going to be talking about is funded from the NIDA HEAL projects. And by the end of the talk today, I'm hoping that you'll leave the webinar knowing more about who these kids are in terms of their risks and struggles, especially regarding their opioid use and drug use struggles, that you'll be able to discuss barriers and successes for prevention interventions on their behalf, and also to be able to understand the components of the prevention intervention that we selected in order to test for these youth, 18 to 24 years old, who are at risk for opioid use disorder. Before I jump into things, I want to acknowledge my team and thank them for the work that we've been doing, because this couldn't be done without them. Dr. Kelly Kelleher is MPI on this project. He's a pediatrician at Nationwide Children's Hospital and vice president for community health and community health services at Nationwide Children's. Also, our team includes multidisciplinary members. So Dr. Xin Fang is a professor of child development. We have Dr. Jody Ford in nursing and Dr. Tansel Yamaza, who's a health economist. Okay, so diving right in. So why did we choose to focus our opioid prevention on youth experiencing homelessness? Well, these youth have some of the highest rates of substance use and opioid use disorder of any youth groups that we know of. In fact, studies across the country and Canada report that in their samples of youth, 79% report using opioids, and 52% of those samples report having experienced a non-fatal overdose. So even though these kids have very high rates of substance use and opioid use disorder, they also report wanting to quit, trying to quit and attempting to cut down, but they report lots of barriers. So the research has identified significant barriers in their efforts. And some of these include just not having a stable home, place to live, insurance or a means to access treatment. They don't have transportation or insurance oftentimes, stigma and peer pressure. Living on the streets, there's a drug culture and drug use is more the norm than the exception. So living on the streets also gives you easy access to heroin and other drugs. Kids report that withdrawal symptoms and stress lead to a lack of motivation. So, and even though 71% report knowledge of take-home naloxone, only a quarter of them have ever reported having one. So another important note is that when people think of youth experiencing homelessness, they think that this is a rare problem, that there are not many youth on the streets. But in fact, recent evidence suggests that there's two to 5 million youth experiencing homelessness every year in the US, 100 million worldwide. And these kids have a higher rate of death. They're 12 times more likely to die. 9% of youth up to the age of 24 will experience homelessness in their lifetime. And one in eight kids are going to run away from home before the age of 18. And we know that running away from home more than two times doubles the odds of experiencing homelessness or literal homelessness by age 24. Now, there's a great deal of diversity amongst youth experiencing homelessness. So I don't know what comes to your mind when you think of these youth. So when I first started working with these kids, I was working with them in a runaway shelter. And runaway shelters work with kids ages 12 to 17 years. These kids often have high levels of conflict in the family, which usually is what leads them to the shelter. Parents drop them off after a fight. Sometimes these kids are running away from home and staying at friends' home or other family members' home. But the majority of those kids go back home. Maybe a small number might enter foster care. And only 8% of those kids report having ever stayed on the streets, literally homeless. Now, the same age kids who live on the streets report rarely going to the shelters. So only a third of kids that you might see between 12 and 17 years old on the streets access shelters at all, runaway shelters. So these kids have disconnected from the family. They've disconnected from the system. Not too many are in school. And for them, the streets are, for them, they consider it to be, they take their chances on the streets rather than at home or within the service system. Even so, replicable evidence-based prevention interventions for these kids that address all of their needs, which are many, are not established. We don't know yet how best to help these kids get off the streets, to recover from alcohol and drug use, to get back into school. There just hasn't been a lot of research to establish what works. Now, shelters are often the front door for populations experiencing homelessness, for adults and for youth. As I mentioned, few youth experiencing homelessness access the shelters. In fact, research suggests only 10% of youth living on the streets access services meant for them. So we've decided that we need to figure out how we can effectively address the range of needs of these youth and prevent opioid use disorder amongst them. I have been working with my colleagues for over 25 years, testing substance use treatments for youth experiencing homelessness, both in the shelters and on the streets. And some of these interventions that we've tested include motivational interviewing, community reinforcement approach, which is an operant-based intervention where you identify reinforcers in their environment that compete with substance use. We've also tested case management interventions, and of course, family therapy for kids residing in the shelters when the family is a viable option for kids to return to. However, in all of these years, testing these substance use treatments with these youth, we realized that we weren't affecting substance use to the extent that we want to, or that we'd hope to. And that's partly because of what I've talked about earlier about the drug use culture on the streets, the high degree of stress, victimization the youth experience while living on the streets. It makes substance use the primary coping strategy. And when you're focused on basic needs, where you're going to eat, sleep, how you're going to stay safe tonight, these higher order needs associated with like depression and dealing with trauma tend to get shelved. So housing became our primary focus. Housing First is a name given to philosophical approach that housing is a basic human right, and it must come before or at the same time as other interventions to make those interventions more effective. Otherwise, we're just working upstream. So the work that we do, because we're addressing so many of the needs of these youth, we need multiple providers with expertise in multiple areas. So we need to address substance use and mental health concerns of youth. We need mental health counselors. We need outreach workers. We sit in our offices waiting for the kids to come to us. It's not going to happen. These youth don't even go to the shelters. So even the shelters aren't reaching the kids that are most in need. Many of these kids, their health and dental needs are extreme. So because they avoid the system, they don't receive preventive care. They wait until the problem is so severe that they can't stand it. And then they go into the emergency rooms. These kids also need employment training and access to education. So now prior prevention work, the prior work with those experiencing homelessness used a treatment first approach to housing. So this requires that youth and adults with mental disorders or drug use problems demonstrate a period of sobriety or sustain treatment engagement prior to receiving housing assistance. I suppose this is to prevent, they're thinking that if they show some stability, they're more likely to maintain their housing once they receive it. The other issue with these youth in terms of prevention services is that many of these prevention interventions are delivered in the home, through families or in school settings. And for youth living on the streets, these are not viable contexts for receiving intervention. Now, Idala and colleagues did some research on housing to justify its, oh, did I, let me go back. Yeah, to justify its impact on substance use amongst homeless adults with HIV. And they found that recent hard drug use was four times higher when these adults remain homeless. But those who obtained housing were half as likely to use hard drugs and needles. They were half as likely to share needles and engage in unprotected sex. So they assert that housing as healthcare holds great promise. That housing should be included as an important tool in any prevention arsenal for those experiencing homelessness. So the work that we're doing that I'm going to be talking to you about our specific approach to prevention with these youth, we're trying to show that housing will lead to a profound reduction in risk for opioid use disorder and other risk behaviors as well. So what are some of the engagement challenges with these youth? Why isn't everybody out there working with these youth? Well, services are available, the shelters, some cities have shelters and drop-in centers, but the youth won't or can't access them. And why don't they? Because these youth often have felt betrayed by the system and its representatives. Their families have rejected them. They've had troubles with, if they were abused or neglected at home and removed from the home and taken into foster care, their foster care experiences were as bad as their home experiences. And those kids left the foster care for the streets. So usually about half of our sample are youth who had been in foster care. So we're working with the ones where foster care failed them. These are the kids who've fallen through the proverbial cracks. Not saying foster care doesn't work, it works for many youth, but just the ones that we work with, it didn't work for. So they've already been through the system and they haven't felt that the system helped them. They've lost connections to family and supportive others. And they've given up on the system. So we believe that you need to have active outreach. We need to go find these kids where they're at. And otherwise these kids, when they're trying to live day to day, they're not gonna take advantage of prevention service. When they're working on basic survival, they're not gonna come in to get substance use treatment. So I'm gonna start talking now a little bit about the interventions that we selected and these interventions are based on some of the prior work that we had done, testing interventions, substance use interventions with youth, but also based on empirical review of the literature on what seemed to have the most promise. So we were using a strengths-based outreach and advocacy intervention. So for this intervention, we can use paraprofessional staff. We don't have to use licensed clinicians. These advocates and outreach workers, we refer to them as advocates rather than case managers, because again, these youth have been case managed out. They don't like the term. Instead, our staff advocate for the youth to help them address whatever goals they have. We focus on their strengths rather than their deficits. So what is it that you have that we can continue to support and grow in terms of job skills or where are they in their educational pursuits? And then we strengthen that. Now, this approach also, we give a high degree of responsibility to the youth in directing what they wanna do and talk about. And you might think, well, duh, everybody does that. Well, and sure, that sounds like the right thing to do, but it's a lot easier said than done. So this has been a theme across the last 25 years, working with these kids. When I'm supervising advocates or counselors or therapists, working with the youth who's engaging in sex work, who's engaging in IV drug use, who's not using, we know they're not using condoms, high-risk behaviors. And the advocate, we spend a lot of time sometimes talking about the difficulties the advocate has in not wanting to just drag that youth into residential programs or just to get them to change. But if the advocate starts asserting their goals and desires upon the youth, we always lose the youth. So our stance, our philosophy is we're gonna be there. And when that youth is ready for more intensive intervention, then we're gonna be there. But if we push it, the youth is gonna leave and we won't be able to be there. Plus, there are other needs in addition to substance use reduction that these kids have. They still need to eat when they're in the midst of their addiction. They still need to have medical care. A lot of our kids don't brush their teeth. They have a lot of dental problems. I mean, it's just, they have a lot of needs. And so we can be with them as they address these other needs. And then oftentimes we see they start to develop hope. They start to feel connected. Trust starts to build. And lo and behold, they're willing to consider intervention for substance use. So motivational interviewing is another intervention that we employ with the youth. This actually has a strong record of prevention in alcohol and drug problems, really severe alcohol and drug problems. And it demands much less of a hard to reach population like those experiencing homelessness. It's only two sessions. You can have more than that, but normally we do it in two sessions. And the youth are responsive to it. It's client-centered, we're gerian. And we're trying to move the kids through the stages of change from pre-contemplation all the way up through action. So this is what we do. We provide housing, we pay six months of rent. The youth, because it's a housing first philosophy, the youth is empowered to pick where they want to live. So we do scattered site housing. They're also, because empowerment is for housing first, the mechanism of change. With the youth deciding how they live, where they live, and whether or not they want to access services or not, the decision is theirs. Now we started off paying 600 a month for six months. Now rental costs have skyrocketed recently. So we've had to raise that a little bit. We also provide utility assistance and we work with the furniture bank as well. So that's the housing intervention. For the risk prevention services we give, we offer six months of strengths-based advocacy and outreach. We offer those two MI sessions. We also do HIV prevention two sessions. Now these kids are at really high risk for HIV and other sexually transmitted infections. And we do 10 cognitive therapy for suicide prevention sessions. Now these cognitive therapy sessions are provided by mental health counselors. So not paraprofessional staff, but we do this because 68% of samples of youth, up to 68% of samples of youth across the country report having a suicide attempt. And amongst those that have attempted, six attempts is the average number of attempts. So this is a very high risk group for completing suicide. In fact, suicide is the primary cause of death for boys. Drug overdose is the primary cause of death for girls. Really these kids, it's really life and death with these kids. I don't wanna be overly dramatic, but for this group of kids that we're serving, it really is life and death. Okay, so our conceptual model. I'll just be brief, because I know this isn't the most exciting part of the talk, but this is what we're expecting. We're expecting that our intervention is going to increase social resources. That is through these connections with others and with services, and that reduced violence exposure is going to lead to increased individual resources. That these youth are gonna develop a sense that they can impact the world around them. That they do have an impact on their world. Because many of these kids have lost that. They have a learned helplessness feeling. Because in the past, it seemed like no matter what they did, they could never succeed. And they were told that by multiple people. Also, we expect these increases in social resources to also reduce their stress. And through this process, we expect them to not develop an opioid use disorder, which is our primary outcome. And we also expect greater change in other substance use. And our secondary outcomes, of course, we also want to improve mental and physical health, housing, employment, education, and risk behaviors. So, who are our kids? They have to be 18 to 24 years experiencing homelessness, and they have to fail to meet DSM criteria for an opioid use disorder. And the reason for that is because we're trying to prevent opioid use disorder. We use the SCID as our diagnostic tool. Now, our project has two phases. Phase one is a non-randomized pilot. In this part of our study, we tested the intervention with 21 youth. It wasn't randomized, but the purpose of it was to be able to see what worked and didn't work with these youth. Because we hadn't put together this type of comprehensive holistic intervention before with youth. So, we wanted to see how well it worked and what we needed to change. We started recruiting December of 2019, and we finished these 21 youth engagement in February. So, we worked with them for six months following that February. And if you remember, lockdown for COVID happened in March. So, we were working in this pilot with youth right during the COVID lockdown, which was a challenge. These are what the kids look like. So, we had about half the sample were male and LGBTQ, which is typical of other samples. Almost 22. All of the kids were Black, African, or multiracial. And we did assessments at baseline three and six months and in-depth interviews with the landlords and youth to find out what their experiences were. Now, well, let's, okay. So, this is what their substance use looked like. You can see all the youth used marijuana. They used it pretty frequently. Alcohol was second. No kids reported opioid use, but three had reported lifetime use. This is a chronically homeless sample. So, they're reporting on average about a year of literal homelessness. And again, these kids are 18 to 24. They completed the 11th grade on average. So, these kids aren't most, they're not finishing school. And as I mentioned before, many of these kids report a history of foster care. So, you might think, you might wonder about foster care. What is it called? Graduation from foster care. Most of our kids didn't age out of foster care. They were in foster care and then left foster care. So, we've looked at samples in the past at how many aged out and it was like less than 5%. So, these are kids who were in foster care and then ran from foster care. In terms of employment, many of these kids get, they can get jobs. Our kids are smart and charming and good at survival, but then they have trouble keeping the jobs. And then usually this employment is part-time and short-lived usually. So, how did it go with us meeting with these kids during COVID? Well, we did pretty well, actually. We were able to engage with them. We had quite a few sessions and quite a few days of contact with them. Now, you can see the HIV session attendance was less than on average one session. The kids really don't like talking about HIV and condom use. And in all of our prior studies, we've had quite a bit of trouble impacting HIV risk behaviors. And this is pretty similar to other studies as well. You can have a short-term impact, but long-term, we have a harder time. I'm curious to see how it works in the housing intervention. So, in this study, if we have better outcomes with the housing. So, housing also was associated with 35% reduction in frequency of use. Now, you might think, well, of course, it's because they were housed, so they were less stressed. They had more support, so there was less need to use substances. Well, not all the research has shown that. So, in other studies where youth were housed, there's not a lot of randomized studies, I believe ours is the first randomized study with youth, but in a non-randomized study in New York City, over half of the youth left the rent-supported housing even before they had to leave. So, they were either kicked out or they left. So, even just keeping youth in housing when that rent is being paid, is not a given. So, all of our kids remained in the housing and they also showed reduced substance use. Other studies with housing first with adults, one of the concerns, so you might think, well, duh, of course they reduce substance use. Well, also, some people believe that if you house youth in their own place, they're going to go crazy with alcohol and drug use, they're going to party, they're not going to have any controls and their drug use will get worse. Well, we're not showing that. And studies with adults don't show that either. They don't show that substance use actually decreases more than comparison conditions, but that it doesn't increase. So, again, in the pilot, no youth began opioid use during the project, which is a good thing because that's our main outcome and they were engaged. So, we confirmed that we could find kids, we could engage them when they're experiencing homelessness into multi-session interventions. Some people think, oh, it's going to be impossible to find a kid who's experiencing homelessness and then have multiple sessions with them when they don't have a home, their phones are not always, they either don't have them or they don't have minutes or they lose them. So, phones are not always a consistent way of contacting them. We found that the best way for us to be able to continue meeting the youth is for the youth to feel connected to us. They don't feel connected to us, it doesn't even matter whether they have a phone that works because they won't answer it. So, I mean, there have been times with the runaway youth where we would do home-based work and we would knock on the door and we could hear them inside there and they weren't answering the door. So, I mean, it's the connection, it's the connection with the provider that we believe is essential to getting these kids in. And once they develop that connection, they're going to find us, they're going to reach out to us. And this is what happens for the most part. All right, so we believe we're providing a foundation to prevent opioid use disorder with this high-risk group of youth who are so at risk of overdose death. The qualitative work, so we wanted to know, well, what did the kids think? So, if we have statistically significant findings, that's not going to matter if the people receiving the intervention don't think that their lives are better. Even though we want substance use to decrease, we want them to be housed, that's what we want, but what we really want is for the youth to feel that their lives are better, that they have hope, they're happy. So, we wanted to ask them, how they feel about the intervention, would they like and not like? So, they did notice positive changes in their life. What was interesting, though, is that they focused on the relationship with the advocate and didn't talk about the housing as much. So, the focus, again, it was that connection. We interviewed landlords because landlords have, in the past, been sometimes a difficult group to work with to house people experiencing homelessness because sometimes landlords would take advantage of youth or adults even experiencing homelessness and not fix things and maybe double charge for certain things that agencies might be paying for, but then they would also charge the individual. In any case, we wanted to know what their experience was working with us, what they liked and didn't like. Well, they liked the consistent rent payments and they liked the opportunity to help others because we framed the project as a way of giving these kids a second chance. A lot of these kids had criminal records, they had evictions, they had poor credit history or no credit history. And so, the landlords worked with us and agreed to house them under these situations. If they hadn't, we probably wouldn't have been able to house any of our kids. We negotiated with the landlords to provide the six-month lease. We did that because we didn't want the youth to experience an eviction after six months if they couldn't pay the rent. Now, we worked with them a great deal during our time with them to get consistent income, whether it was through entitlements or employment so that they would be able to cover their rent. That was a huge focus of our work. But if they didn't, we didn't want them to have the eviction. The landlords wanted the full year, of course, and then they also didn't like problematic tenants, of course. So, these youth, what'd we learn? These youth are very engaged. Even using remote strategies, we did a lot of texting and FaceTiming, a lot of, actually, even over Facebook, even though that's not the popular platform for youth, for our youth, they could easily access it on computers and libraries, et cetera. HIV attendance wasn't as good as we would want, but our landlord and youth experienced positive things and we had some housing barriers and struggles, especially during this pilot that, as COVID hit, services that they typically relied upon closed or hours became restricted. So, even the drop-in center, which was 24 hours, so a lot of our kids would sleep there at night, closed. And so, these kids, there was no place for them to shelter in place. They won't go to the shelters and they were living in the woods and in abandoned buildings and cars. We also had a high turnover in workers. A lot of our workers didn't want in-person contact. So, we need to have in-person contact with the youth or we wouldn't be able to engage them. Once we have in-person contact, then we can integrate the texting and FaceTiming. But if we don't have that connection first, the texting and FaceTiming would drop off pretty quickly. So, in-person contacts, the combinations seem to be okay, but it's a little bit harder than totally in-person. All right, let me just check time here. So, just now briefly, our phase two. And our phase two recruits 240 youth. We are signing half to housing and all of those risk prevention services. And we're testing that against just risk prevention services alone because we're trying to identify the unique impact of housing on our outcomes. So, recruitment's going well, data is entered. I'm able to provide to you some information on who these kids are. So, in our phase two, the sample looks pretty similar to the pilot. A primarily black and multiracial sample, equal male to female. And then up to a third of our youth are LGBTQ. About 35% of our youth reported having attempted suicide with average number of five attempts. Opioid use, 70% of the sample reported trying 5% within the last three months. But again, in terms of substance use, marijuana and alcohol are the most commonly used with stimulants, a third, number three. And again, a highly, highly chronically homeless group. Oh, wait, did I skip? Okay, and then this slide is just maybe to make, maybe it'll make you a little bit sad, but it's a reality and it's the reality of our youth. Is that 95% of the youth in the sample reported childhood abuse experiences. And oftentimes these kids, when they're experiencing abuse and neglect in the home, they leave the home on average around age 15. They start running away on average around 13, both the runaways and the street living youth, but 15 is when they usually just go to the streets. And they're leaving the streets because they're thinking it's gonna be better than at home. Then if you look down here at ever experienced street victimizations, 81% of the youth in our sample reported street victimization. So they're going from the frying pan into the fire. And then also it's reappearing in their love relationships as well. This is intimate partner violence, half of them are reporting. Okay, so some just tiny preliminary findings. We really haven't analyzed our data because we're still cleaning data and collecting data. So, but for this talk, I just wanted to give you just a little bit. So no youth yet has been diagnosed with opioid use disorder follow-up. That's good. Our depressive symptoms and suicidal ideation scores have decreased. And as far as housing goes, 80% of the youth have maintained their apartments at nine months, 72% at 12 months for those that have been provided the housing. Now remember, housing rental support ended at six months. So this is six months after rental support ends. We got so many of these kids still in their apartments, which is, I think, amazing. Like I said, even when the rental supports are being paid in other programs, the youth are leaving. So, and in just the risk prevention services, the strengths-based outreach and advocacy, we still see that the kids are maintaining some stability in homes. Now, even though we don't provide rental payments for housing for those youth, we work with them in the system to get them in housing programs that are available in Columbus, Ohio. And so what are our conclusions? This is my last slide. Even though these youth are at such high risk for opioid use disorder and overdose death, they're difficult to engage, we show we can find them, we can engage them, and they'll come to multiple sessions with us. These youth, they want relationships, they want connection. And it's that relationship with the advocate that is essential. We believe essential to uptake of our intervention and community-based services. Many times the advocates went with the youth to their appointments, otherwise youth wouldn't go. And why don't they go? Well, they're afraid, they're overwhelmed. It's just, even though these kids are 22, 23, they didn't get prepared for the world the way that housed kids do. Housing alone we think is likely insufficient to prevent opioid use disorder and substance use disorder. We need to wrap these kids with these holistic services. And youth, we can't wait in our offices or in the shelters for them to come. We have to go and find them and serve them in settings that they'll access. Another summary point is that there's limited affordable housing out there. We did struggle quite a bit to find apartments that weren't just so inhabitable. It was just, the rent's just going over the top. But the youth's prior evictions, criminal records, et cetera, that did create challenges. But working with the landlords, we were able to overcome some of those challenges. And so that's it. Thank you for listening. Thank you, Dr. Slesnick. It's so important and helpful to hear about this high-risk population and to learn about strategies to support them. It's exciting preliminary data. So right now, if we can take a few minutes to take questions and answers from the audience. If people have questions, please put them in the Q&A section below. Some of my questions, one thing is you mentioned that it was hard to engage the youth in the HIV sessions. And I didn't know if there are different language or different ways to approach youth as we think about harm reduction. Particularly, I have heard concerns about housing where if someone's living alone, you're kind of putting them in housing and they might be alone and really wanna make sure that they understand risk for opiate overdose and wanna be talking to them about naloxone, but they're living alone. So I was just curious how you guys have approached those conversations or terminology that maybe works to better engage the youth. Well, for HIV prevention, what we stopped doing was a while ago is calling it HIV prevention session and just trying to integrate using condoms into the conversation when we talked to them about having sex with others. And we try to then make it less formal because when we would say, okay, this week we're gonna schedule our HIV prevention session, then none of the youth would stop showing up for their session. But if we say, hey, let's go get your ID or let's go to the social security to get your disability, then, oh, they'd show up. But so then what do I talk with the advocates about is maybe just even talking about some of the prevention strategies as they're driving. So to make it not a formal focus that the youth dislike. Now, we also have to have them practice condom application. So that one we had to do in the office, but we would also be able just to try to integrate it and not call it an HIV session, HIV prevention. In terms of the kids living home alone. So you're right, there are kids who living alone, they've never done it and they're actually afraid. And we've had the experience where some kids didn't want to move into their apartment because we didn't understand it. So they picked it out and the rent's paid, but they won't move in. So we talked with them, well, why don't you move in? Well, I'm afraid I've never slept alone. I've never been alone in my own place at night. Again, like I said, you're like 22 year olds, but you're really dealing with kids who haven't had the same preparation for independent living. So yeah, so what we would do, we would talk about how they could feel safe. Could they have a friend come over? But you have to be careful with that because a lot of the kids, that was an issue also on the other side. So they would have friends come and crash at their place, which puts them at risk for eviction. So it's a touchy issue. One of the things we suggest for the future based on this is maybe to have kids live in pairs. Our project didn't do that, it was to live alone. But I think that could help with the loneliness. Got it, yeah. And then one thing I was also curious about is, do you have ideas of like what helped them to stay in housing? I mean, I think, you talked about the strengths-based approach, but was there anything else, like kind of concrete things that kind of helped them to be successful in staying in the housing? Well, I think that the kids want to be a part of our social group. I don't think any kid wants to be on the streets and alone. So I think there is an intrinsic motivation to be part of our social group. And so I think once we were able to tap into that it's possible and that they're worthy and capable and that it can happen, that they started to access that part of them again and to feel that what they did mattered. And it's like giving them, it's like helping them have small successes. So you give them little tasks and then they succeed. And this is how you start building self-efficacy and confidence, which I believe is core mechanism of changing human behavior. I think Bandura felt that way too. So yeah, this is what I believe, yeah. Got it. And I was also curious about, I mean, you talked about that, I mean, this is a very high risk population. And so I imagine the advocates, as a clinician, you often get really worried about your patients when they're higher risk. And so that desire to kind of be more directive and kind of follow more of your agenda as a clinician in terms of when you're worried about risk, I think can be really strong. As you mentioned around the advocates, that the advocates kind of often had their, a little bit more of their own, it was a struggle to kind of keep it focused on what the youth agenda was. And I was wondering if there's anything you, kind of what you do with the advocates to support them and kind of staying focused on what the youth agenda is, as opposed to kind of shifting to the advocates agenda. I think that's hard for us in healthcare that we often kind of get pulled towards our agenda and be helpful to hear what strategies you used. Yeah, this is really important because when you're working with groups like youth experiencing homelessness, you're dealing with people who've experienced extreme amounts of trauma, extreme amounts of trauma. And often the advocates who are willing to work with these kids are also people who have experienced trauma in their past because they're empathic and they want to help others. And so sometimes the trauma of the youth can re-traumatize the advocate. And then that brings all sorts of coping responses up for the advocate that may or may not be functional for themselves or for the youth. And while I don't like to do therapy of advocates at all, what I do is we meet every other week for two hours. I have right now four advocates and we meet to talk about each of, I mean, it's supervision. We talk about each of the clients, but I'm not sure everyone else does that. Like you set two hours aside every other week just to talk to them about their experiences with the advocates and what's been a struggle for them and how to resolve that. So I spend the time every, that's priority on my schedule and I make it on theirs too, that this is, they need to come. They may not need supervision in the traditional, this is how you do the intervention, but they need supervision for their own responses as well. And if it looks like they need more emotional work, of course referral to psychotherapy is important. Got it, yeah, just so important to provide that extra space for supervision to support them. And then one other question I had, and if there's other questions from the audience, please type them in, but I was just curious how you engage the landlords and whether these are kind of apartments are kind of spread across the city or if they're in more of kind of a concentrated area with just given high cost of living and whatnot and strategies to kind of motivate the landlords to participate in addition to the six months guaranteed rent. Yeah, these apartments are all over the city. And so what we do is we, well, the youth are able to find, if they can find an apartment, we'll work with that landlord and see if we can get them in. But other than that, we have a pool of landlords who own apartments all over the city and we would approach them and talk to them about the project and we would ask them about giving these kids a second chance and helping us help the kids. So we would get landlords who would participate partly because of that, they wanted to give back and help, but also money helped. So some of them wanted like three times the rent or twice the rent at baseline. So we ended up kind of paying through the nose, I think more than what most people would. So I think they also had us pay for it. So we paid twice the damage deposit, maybe twice what down payment for rent would be, et cetera. And then also if a kid did damage an apartment, we would pay for it. Got it. And did that come up often or was that, I mean, people worry about that kind of thing, but I didn't know that in reality that actually is something that's. No, I would say, okay, what's often? Let's see, I would say it comes up more than once or twice, but less than a hundred times. So I don't know, maybe 25 times. But I mean, we had one kid, maybe there wasn't this project, but it might've been the last housing. We had a kid drive a car through the front door of the apartment building. No, I think there was, I think that happened twice. So we didn't have to pay for that, but yeah, sometimes it's bad. And sometimes it's bad. Yeah, but it sounds like it's helpful that they have someone to call and kind of who's supportive and responsive in terms of trying to address the damage. Yeah, that kid wasn't our kid. It was like an abusive partner. So the police, I mean, yeah. But the landlord will call us first when there's problems. Yeah, it's not fun. I must say, it's not an easy, it's not easy between housing and it's not cheap, but either it's homelessness or the opioid epidemic. So I think it's the benefits outweighed the costs for housing. And it's not gonna be simple, it's not gonna be easy, but I do think it's the way to go. And we have more work to do to figure all the kinks out. Yeah, I think something we've seen is just it can be hard to engage the community to kind of be welcoming of housing first intervention. But some of the things that have been done in Boston have been bigger kind of housing 60 people as opposed to one individual. And it sounds like it's nice that you have this spread out across the city, but yeah. Yeah, we didn't get community complaints because they weren't all in one building, which isn't technically housing first. It was also just curious like how you found the landlords to approach, like if there were any characteristics, like kind of just word of mouth, you knew these people were maybe more willing to engage with the project or just cold called landlords and figure it out. We just went to every land. So the shelters have lists of landlords that they rent to, we got that list. And so we approached just about every landlord in the city. And I mean, it takes a lot of time. And yeah, and we just go and introduce ourselves and start negotiating. And then the ones who would be willing, we added them to our list. Yeah, it's just a lot of footwork. Persistence, well, these kids are lucky to have you guys. So, but any final words for the audience? If you have any questions, if you have any desire to work with these youth or have worked with one and you have questions, feel free to reach out to me anytime. Well, thank you again so much for your time and your expertise today. It was really exciting again to learn more about strategies that work in terms of supporting these kids and their really important patient population for us to be thinking about, or important population group. Thank you very much. Thank you everyone. Thank you. Thanks for attending.

opioid use disorder prevention

youth homelessness

housing

risk prevention services

strengths-based outreach

motivational interviewing

suicide prevention

housing stability

youth-directed goals