There is a serious gap in the continuum of services between Prevention and Treatment services for high risk youth and young adults at early stages of substance use. When we speak to these youth what we often hear is, “Prevention, education? I know it all! I could even teach the course!” Or, “Treatment? I’m not addicted! I’m just doing what all my friends are doing. And, I can stop anytime I want to!” So what happens to these adolescents and young adults who are often lost to the system and fall through the gaps? How do we effectively engage them to change their trajectory and prevent addiction and dependence if the current continuum of services does not include Early Use Intervention?
In a 2012 review by Carney and Myers (“Effectiveness of early interventions for substance using adolescents: findings from a systemic review and meta-analysis,” Substance Abuse Treatment, Prevention and Policy 2012, 7:25 http://www.substanceabusepolicy.com/content/7/1/25), only nine evidence based practices were identified. All but one provided limited interventions for the target population, usually one to three individual sessions. In NYS, Teen Intervene, one of the practices mentioned in the review, has been identified to engage youth at this critical time in their spiraling use of alcohol, prescription drugs, opioids, and/or heroin. This model, although effective for some, is limited in that it provides only 3-5 counseling services to high risk youth and then depends on referrals to other resources in the community. However, if there are no appropriate resources, or treatment is not the right intervention at that time, or the youth refuses the referral, there are no viable options. All the models identified by Carney and Myers require that the youth, who hopefully has developed a positive relationship with whomever was providing the initial counseling, must now start all over again with another community-based counselor. We know youth typically have difficulty establishing and maintaining trusting relationships with others. They often do not follow-through with these referrals. These youth are lost to care.
Experience has shown that an approach for effectively engaging this high-risk population is a community based, early intervention model that provides intensive case management supports with wrap around services, an opportunity to develop new and healthy relationships, and a focus on goals that are clearly identified and driven by the youth’s vision for the future.
In the aftermath of Hurricane Sandy, The Staten Island Mental Health Society (SIMHS) received funding from the American Red Cross and the Staten Island Foundation to implement an evidence informed, community-based early intervention model, Transition to Independence Process, TIP, (Hewitt Clark, University of South Florida). The targets were high risk youth ages 16-24. Substance use was found to have increased in response to the stressors associated with the Superstorm. In the course of one year, 481 youngsters not connected to any prevention or treatment services were assessed, 86 were engaged in the TIP process and 31 were admitted to either a mental health or substance abuse clinic for treatment.
Hurricane Sandy related funding ended in 2016. Fortunately, in 2018, SIMHS, now a Division of Richmond University Medical Center (RUMC), received funding from NYC DOHMH. South Shore SafeTY.net was launched using the TIP model.
The TIP approach is flexible, positive and life affirming. Unlike most treatment models which focus on problems and weaknesses, TIP is a process that builds on the strengths and interests of each participant and provides trauma-informed person-centered care. South Shore SafeTY.net (SSSN) creates an environment that is free from stigma, developmentally appropriate, and accessible. Youth are engaged in healthy activities, form positive relationships with others, and develop a plan based on their personal goals and dreams. Average stay is 12-18 months.
TIP targets the domains of school, work, peers, and family. Working through the domains and with people in their environment, youth build confidence, find their voice, and develop personal autonomy. The ability for youth to take action and change their past trajectory makes this program unique.
Life Coaches, partnering with Peer Advocates, work with each youth on an intensive and individual basis to help develop and implement a feasible plan to reach personally identified goals. Harnessing available resources, including family members, peers, significant others (school teachers, coaches, etc.), and other community resources/services, the Life Coach builds “virtual” teams focused on helping the youth move towards accomplishing identified goals. Because these teams are “virtual” the stakeholders on each team change according to the needs and goals of the youth.
When ready, youth are engaged in work/study opportunities in fields of interest with a goal toward future employment. The time and effort of each youth is recognized as valuable. Each participant receives a stipend for their work.
One of the most important components of SSSN is the opportunity for healthy socialization. We have found that many of our youth lack good socialization skills, are often vulnerable, and are easy targets for gangs or peers engaged in destructive behaviors. SSSN provides youth with many healthy socialization opportunities for skill development and formation of healthy friendships. Activities have included attending Broadway shows (it’s surprising how many have never left the Island, let alone attended a Broadway show), afterschool, weekend, and holiday activities, parties, college visiting, and more.
Since the startup of SSSN in January 2018, 33 youth have been engaged, 23 have a history of trauma, 18 have co-occurring mental health disorders, and more than 50% are employed in work/study and are either completing their high school degree or are enrolled in a college program. All but two are people of color. Providing services that are culturally and linguistically appropriate has been vital to goal attainment. Now established, program numbers are growing.
The evidence of the success of this early use intervention approach is reflected in the stories below (their names have been changed):
Daniel was out of work and school. He had an extensive history of substance use and suicidal ideation. He needed assistance exploring his sexuality and facilitating communication with his divorced parents. Through SSSN, Daniel was able to find his voice. He wants to work in a nursing home and has completed a Certified Nursing Assistant program. Communication with his family improved. He “came out” and began dating and learning how to build healthy relationships. He no longer has suicidal ideation, goes to therapy regularly, and is doing well.
Tony came to the program homeless. He is Autistic and has experienced trauma. He had issues with personal hygiene and healthy eating, and was being bullied. Once enrolled in SSSN, Tony obtained his GED and was Salutatorian of his class. He began taking better care of himself. He began supportive employment doing janitorial work at the Staten Island Pride Center. He then graduated from the AHRC Cleaning Management Institute completing the Basic Custodial Certification Course. Tony now has a permanent position at the Staten Island Pride Center. He is currently living in a Transitional Independent Living Program.
William came to the program in distress. He had suffered both physical and psychological abuse from his step-father. He was out of work and school. At SSSN, William was helped to find purpose and begin to heal from his past trauma. He began supportive employment at the SSSN site doing janitorial work and graduated at the top of the class from AHRC’s Cleaning Management Institute. He completed Basic Custodial Certification and obtained work at Fort Wadsworth in a fulltime union paid position.
April was often left to care for her older sibling’s children and was responsible for the upkeep of the home. She was very isolated and lacked confidence. She had no job, was out of school, and smoked marijuana heavily. She is now working full-time at Stop and Shop and was just accepted into The College of Staten Island. April has declared her major as Early Childhood Education and hopes to run her own preschool one day.
Ira was homeless when he came to the program. He was out of school and work. His girlfriend was 5 months pregnant. Through SSSN, Ira completed NYS Department of State security training. He improved his relationship with his girlfriend and family resulting in moving into the home before the baby was born. He has been linked to the Fatherhood Initiative at United Activities Unlimited and is looking for full-time work. His daughter is healthy and doing well.
All these high-risk youth and young adults would likely have been lost to addiction without intensive, community based, individualized early intervention. This type of early intervention model can be replicated and clearly can make a difference for youth to help reverse the course of their substance use.
Fern Aaron Zagor, LCSW, is Principal, Fern Zagor Consulting LLC, Former CEO, Staten Island Mental Health Society. Rosemarie Stazzone, RN, is COO and CNO, Richmond University Medical Center. Melissa Singer, MS, is Program Manager, SafeTY.net Program, SIMHS/RUMC. Basilio Allen, BS, is Program Coordinator, South Shore SafeTY.net, SIMHS/RUMC.