Harm Reduction: Advice from Leaders in the Field

Harm Reduction: Advice from Leaders in the Field

A youth uses the phone at the Preble Street Teen Center

USICH spoke with staff from three model programs using harm reduction to help youth experiencing homelessness: Jon Bradley, the Associate Director of Preble Street in Portland, Maine; Vicki Lawton, the Director of Services for the Community Action Network of Western Nebraska; and Heather Brown, the Director of Youth Services for Outside In in Portland, Oregon. They shared lessons learned and tips on how to build trusting relationships that can help youth find stability on their own terms.

Read what they shared on the following topics:

USICH also spoke with Tricia Clerk a young woman who experienced homelessness in Portland Maine and who found stability after participating in a harm reduction program.

Read a note from USICH Deputy Director Jennifer Ho on how using a harm reduction model for youth can help us accomplish the goal of ending youth homelessness

What is Harm Reduction for Youth?

A harm reduction program should empower youth by offering a support system that allows youth enough control to make their own positive decisions and then space to safely see the outcomes of these decisions. Since youth are by definition young, they are still gaining their footing on what it means to live life as an adult. For the highest risk youth to gain this footing, a safe space with a low-barrier for entry is necessary, but youth also need access to adults they can trust and services that can help them break the cycle of street-involvement. Harm reduction for youth means meeting a youth where they are in life and letting them make decisions about the program they are in and their own futures.

Why is a harm reduction approach necessary?

Harm reduction can be very effective for helping youth who are the hardest to reach and have the greatest need. “If we only offered a zero-tolerance approach or attempted to restrict entry for those who were currently using illicit substances, then almost all of the kids we have helped over the years would have been screened out. Our program targets youth with the greatest needs and the riskiest lifestyles. If they could have just gotten off the street and clean on their own, then they wouldn’t be where they are now, which is in need of a program willing to meet them on their own terms,” said Heather Brown of Outside In.

Two and a half years ago, the Community Action Partnership of Western Nebraska was a zero tolerance program: if youth were using, they were kicked out of the program and services. “Our success rates were low, below 50%. We realized we were seeing the same youth cycle in and out until they were too old for youth services. We weren’t helping youth with the greatest needs. So we made a shift to a harm reduction, trauma-informed model. Now our success rates are up to 75%” said Vicki Lawton. “The shift from zero tolerance was hard, but it was absolutely worth it. Helping just one youth who wouldn’t have been helped before has an incalculable moral benefit, but the benefit to the taxpayer is calculable: many youth who develop a history of homelessness at a young age never break the cycle and become adults who are chronically homeless and incur high costs to public systems.”

In Portland, Maine, Preble Street Youth Services evaluated the population they are serving and found that the youth in their programs have histories of trauma, mental illness, and substance abuse. Ninety-four percent of youth in the study had mental health issues. Nearly one-hundred percent were using illicit substances. Nearly half had considered or attempted suicide. Eighty-two percent of women and thirty-eight percent of men had experienced domestic violence. “Using a trauma-informed approach, it becomes clear to our staff that for many youth, substance abuse and some other risky behaviors can be mechanisms to cope with past trauma, but these behaviors can also create new trauma. At Preble Street Youth Services, we have found that to help break this cycle we first need to get youth in the door. To do that, we offer whatever it is a youth needs at the moment. Usually this is food, but it can also be clothing or a bed. Once we get them in the door, they end up using more services than they initially said they were interested in, and the more services they use the better chance they have of having a positive outcome.”

Five ways to build a successful harm reduction program

1. Build Trust.

All three programs we spoke with said that building trust was a critical first step to connecting youth to the services that would help them gain stability. To do this they recommend building an intake and review process that allows youth to express what they want and then act on what they ask for. Allow the youth to have a say in how the program is built.

2. Train Your Staff on Harm Reduction and Trauma Informed Care.

Vicki Lawton had to retrain her staff when the Community Partnership of Western Nebraska shifted to a harm reduction model four years ago. “It was a difficult shift because it required a fundamental culture change for our staff. A zero tolerance policy gives staff a sense of power over the youth:  ‘If you don’t walk the line, you’re out of here!’ But that isn’t a way to build relationships and trust. And that is what these youth need more than anything: trust. The two main objections I had from the staff as we went through this switch were: 1. If we let them come as they are and don’t eject them for abusing substances, then they won’t know what the real world is like; and 2. The youth will end up setting the program goals and standards. The real world is not based on a one strike and you’re out system. You certainly can get arrested, fired, or kicked out of housing for uncontrolled substance abuse, but many people use for years without losing their jobs or houses. Instead of just declaring that substance abuse is always bad because we say it is, it is better to work with the youth to help them see for themselves the negative ways substance abuse affects their lives and future. The second point of objection is very much true in a sense, but it isn’t in my opinion a negative aspect of a program. Having a harm reduction approach doesn’t mean you lose control, but it does mean that you tailor your program to match the youth instead of forcing the youth to fit your one-size-fits-all program. When you think about it this way, it is obvious that youth will stay engaged longer when they have a say in the programming, when they have a say in the direction of their lives.”

3. Involve Youth.

Involving youth in your program is important to building trust, but it also ensures that your program will work effectively for other youth. All the programs we interviewed allow youth to tailor their own service plan to meet their needs, but they also allow them to give feedback to adapt the services offered to better meet the needs of future youth. At Preble Street and Outside In, the youth are also involved in the interview process for hiring new staff, which empowers youth and gives new staff a deeper understanding of the program before they come on board. All three programs also make an effort to hire youth who have been through their programs.

4. Use Outreach to Meet Youth where They Are in the Community and Make a Positive Initial Connection.

What your outreach looks like will depend on your community, but a few basic principles are followed by all three of these programs. First, go to the places where youth experiencing homelessness are likely to hang out: parks and campgrounds, free outdoor festivals, and 24-hour stores. Second, offer them what they are looking for: Preble Street gives out water bottles and hats or sunscreen depending on the time of year and Outside In offers free medical care through their outreach clinics. Third, offer a low-barrier place to stay when they have none and need one: Community Action Partnership has a relationship with all of the 24-hour stores in the 11 rural counties in their region and a store owner will call them instead of the police if youth are loitering. All of these approaches create a positive first contact with youth experiencing homelessness instead of punishing youth for being in their situation. This type of contact lets youth know that organizations are safe and increases the likelihood youth will seek help.

5. Build partnerships with other organizations in your community to fill any holes in your service network.

Since youth need a wide range of services (different types of housing, health care, mental health care, substance abuse treatment, high school and college education opportunities, employment training, and access to employment opportunities, food, clothing, legal guidance, help with benefit enrollment, etc ), it is important to forge partnerships with the other organizations that can provide these services. The programs we spoke with act as an intermediary for many other services at community colleges, hospitals, and other homeless shelters in their communities by making the connections between their programs and those at other facilities as seamless as possible.

Harm reduction, meeting a youth on his or her own terms and offering a safe space for a youth to access service, can help youth experiencing homelessness and engaging in risky behaviors find stability and direction. All three programs stressed the urgency of need when working with youth. “When it comes to helping youth we don’t have time to lose, but when we work with our youth in partnership, it is amazing the things our young people can and do accomplish,” said Jon Bradley.

Four Local Solutions from Nebraska, Maine, and Oregon

USICH recognizes that all communities are different there is not a one-size-fits-all program plan. Our experts share a few techniques that have helped them serve youth better in their communities. Some of these tips may help your programs as well.

1. Don’t let a large service area get in the way of effective outreach.

Vicki Lawton at Community Action Partnership of Western Nebraska

Our service area is 5.5 hours driving distance across. When you work with youth, especially youth in crisis, you realize pretty quickly that timing can really matter - if you take 3 hours to get to a youth who needs help, you may be too late. We have set up “satellite sites” all over our service area to help limit response times. A satellite site is often just a host family’s house, but the key is that we have a number of people in all of our 11 counties who are willing to serve as a first contact and offer a safe space in short order so that a youth doesn’t have to wait for someone from our main office to reach them.

2. If you have more demand for shelter than you have supply, consider screening by age to make sure the youngest, most vulnerable youth are safe.

Heather Brown at Outside In in Portland, Oregon

Unfortunately, the current demands for youth shelter exceed our local capacity. Youth are being turned away most nights because the shelters are full. We make sure every possible bed is full before any youth is turned away, but limited resources are a reality here in Portland, Oregon. Studies have shown that younger youth are more vulnerable on the streets so we prioritize shelter entry by age. The shelter currently operates with a window of access for younger youth by opening at 8:45 p.m. before opening up for older youth at 9:30 p.m.

3. Keep those who transition out of your program connected to your services, but also maintain a youth only environment in your drop in center or other common areas.

Jon Bradley at Preble Street in Portland, Maine

Our drop in center and shelter are open to 12-21 year olds. It is important to maintain this age range so that all the youth feel safe and comfortable in our common spaces, so that they feel the space is designed for them. But if a youth who can still benefit from our program turns 22, we don’t just cut off contact. Doing so could be very damaging to a young person’s sense of direction and trust and could harm their stability. We opened a back door on our center so that youth 22 or older can still meet with case managers and receive mental health and all other non-group services, but they can’t just hang out in the center with younger youth.   

4. Make sure you have different types of housing available to support youth as they gain stability.

Heather Brown at Outside In in Portland, Oregon

The path to recovery isn’t always a straight line and it can look very different for different people. We have a range of housing options available for youth. This range includes both transitional and permanent supportive housing but it also includes wet housing, damp housing, and clean and sober housing. If a youth is ready for clean and sober housing, but they are placed in housing where they are surrounded by people who are still using it can very quickly lead to relapse. If a youth who is not yet ready for clean and sober housing is placed in such a unit, they will likely find themselves homeless again. We work with youth on an individual basis to find a housing solution that will help them along their path to recovery. This allows us to support youth to move into more clean and sober housing options as they progress in their recovery.

A Harm Reduction Approach Helped Tricia Clerk Find a Job, Housing, and Direction in Maine

Last year, Tricia Clerk was 18. She lived with her mom in Bangor, Maine where she attended college and worked the night shift at a shipment company. Then her mom died. She had no transportation so she could no longer work and couldn’t pay bills. Her very stable and secure life disintegrated in a just a few months. She relied on family and friends for a while and moved to another town to follow a job lead but nothing stuck. It isn’t easy to find work that pays enough to make ends meet when you don’t have transportation and have very little experience.

Tricia is an idealist. She is an artist and dreams of being able to make enough to live on from her art. She spent several months hopping from town to town selling art on the street and sleeping wherever she could: at hostels, on the street, at houses of people she would meet at coffee shops or she would spend the late night hours in 24 hour diners. She has come to realize that, although she has always felt lucky, her life wasn’t always safe. She was starting to hitchhike regularly and had been followed by men late at night on the streets. One night last June at a Denny’s in Portland, she was preparing to hitchhike out of town when the woman behind the counter told her about Preble Street and paid for her cab-ride to Preble Street’s Lighthouse Shelter.

She and her case manager have worked together over the last six months to create a plan for stability designed for her and based on her experiences and gifts. Chris Bicknell, the Director of Youth Services, said “When Tricia arrived she was unwilling to engage in services and look at any options for employment and had the self defined goal of 'traveling' (train hopping) and selling her art on the streets. We did a lot of work with her about the risks involved with such choices both for the short and long term. She even did a little traveling after about 3 months with us, but returned within two weeks and began to engage in case management, mental health, education, and employment services. If we required her to participate in services that we deemed necessary, she would have been more resistant to engaging with staff and our programs when she was ready and it could have scared her off altogether. Instead, we were able to let her explore her options at her pace while being realistic about the risks and our concerns in a way that she did not feel judged or forced into a decision she wasn't ready for.”

Tricia participated in Preble Street’s Street Academy where she gained help finding a job. She was offered an internship at the University of Southern Maine (USM) through a stipend program where Preble Street paid her salary for a trial period as she gained experience. After the internship was over, her employers were so impressed they offered her a full-time job. She begins this new position in two-weeks and two-weeks ago she moved into her own apartment. She will also be able to take some college classes for free at USM as a part of her employment agreement.

She says that what made the difference at Preble Street was the way the staff had a personalized approach and respected her idealism and her art. They recognized that individual relationships matter, allowing youth to switch from one case-manager to another without any hard feelings. “The rules at Preble Street are there for a reason, the rules clearly improve safety and help youth find stability,” she said. She was empowered by her role in interviewing new staff for the program and said that the staff at Preble Street cared about her views. “As an artist and an idealist, I have always felt like a bit of an outsider like I have a different view of the world than my family and others… At Preble Street, they didn’t try to change that or restrict me before they would help me find my footing.”