“Demand [for mental health and substance use supports] has increased. Serious changes need to be made to support youth and connect with them at a level that resonates…”

~ Survey Respondent 

This post is the second in a blog series highlighting the findings from our Canadian Institutes of Health Research-funded study focused on promising mental health and substance use practice adaptations used by front-line providers during the COVID-19 pandemic for young people who are experiencing or have experienced homelessness.

In our first blog post, we highlighted our preliminary findings on pandemic impacts on mental health and substance use patterns. The findings are based on answers to questions from an electronic survey sent to Canadian front-line providers who work with youth (16 – 24 years) who are experiencing or have experienced homelessness. In this post, we use the same survey to focus on responses pertaining to front-line practice adaptations. 

The second section of our 26-item survey was the shortest. Before survey respondents moved on to the third and final section on promising practice adaptations, we wanted them to give us a sense of how the pandemic had impacted front-line practice at an agency/organization and at a  provider level. Importantly, we wanted to learn what providers thought about young people’s satisfaction with these practice adaptations. 

Service Restrictions

The majority of providers noted substantial restrictions in service delivery at their respective places of work. A small but notable number responded that their agency/organization had completely shut down and was offering no mental health (18%) or substance use (12%) supports. Half of respondents reported that all of their services were being delivered off-site. 

Mental Health Adaptations

The majority (81%) of respondents shared that they had adapted their mental health practice by delivering services over the phone. Other adaptations included offering virtual mental health supports through video chat (68%) and/or social media (45%). Many (59%) were also increasing mental health information available on-line. A small number (18%) of providers reported directing youth to mental health mobile applications. Regardless of the medium, most (58%) providers noted they had increased their outreach (virtually and/or in-person) specific to mental health.

Substance Use Adaptations

Similar service adaptations were reported in regard to providing substance use supports, albeit to a lesser extent. The majority (61%) of providers noted they had moved to delivering services over the phone. Virtual adaptations included the use of video chat (49%) and social media (28%). Almost half (47%) shared they had increased the amount of on-line information related to substance use supports. Mobile applications were less commonly used (8%) compared to use for mental health supports. Notably, less than half (39%) reported intentionally increasing their outreach and a small but remarkable number (14%) reported they had made no adaptations to the way they deliver care (the latter must be interpreted with caution; it may be that these providers already had “pandemic-proof” substance use services in place).

Youth (Dis)satisfaction

After reviewing mental health and substance use provider practice adaptations – primarily consisting of phone and virtual supports – an obvious question comes to mind: What if youth are unable to access these new ways of delivering support? Perhaps this is why more than half of respondents reported they sensed young people were neutral (“take it or leave it”), dissatisfied, or very dissatisfied with mental health (64%) and substance use (54%) practice adaptations, and almost one quarter (24%) were unsure what youth thought of adaptations specific to substance use (in our previous blog post we noted that approximately half of providers were also unsure where youth were accessing appropriate harm reduction supports). The insightful comments on the reported ambivalence to mental health and substance use practice adaptations mostly centre around inequitable access and lack of human connection.

Inequitable Access

The move to remote care is based on the premise that young people have access to a phone or the internet. Many providers shared that this is not the case and a large barrier to accessing mental health and substance use supports – especially for young people who are sleeping rough and struggling with mental health and substance use. Importantly, these forms of communication may not be as safe as in-person conversations. 

“Many youth have not been able to access services because they have limited resources, like working cell phones or Wi-Fi so they have not been able to connect for services.”

“Many of the youth we serve do not live in a place where they feel safe to attend online groups for several reasons, including their partners or roommates don’t know they are in engaged in the sex trade.”

Human Connection 

The importance of face-to-face-human connection came up often in the survey responses. While many providers acknowledged that phone/virtual supports may be more convenient for some young people (e.g., youth no longer have to travel – sometimes long distances – to access care), the majority wondered whether this might be an “inferior” counseling medium, citing the importance of being able to “lay eyes” on the youth they serve – especially the longer the pandemic drags on.

“Initially, clients seemed to be relieved to have continued access; however, over time they have been less engaged (missing appointments) and frequently requesting in-person sessions. Feedback [from youth] has been that they need more personal connection [because of] an increase in loneliness and feeling isolated.”

Looking Forward

It is understandable that, given the need to align with current public health guidelines, most youth-serving agencies/organizations have adapted by pivoting to virtual or phone supports; however, the implications for young people who depend on these services – especially the most marginalized (e.g., youth sleeping rough) – are worrisome. Additionally, as we head toward the winter season and the weather becomes colder, the demand for on-site services will likely rise. 

In our first blog post, we identified key implications for policy, practice, and research so we will not reiterate them here except to emphasize the crucial need to adopt an equity-informed response when considering how best to serve young people during this pandemic. Practice adaptations that require the use of a phone and/or the internet mean young people must have access to these resources along with safe spaces to communicate. Agencies/organizations must be careful not to inadvertently perpetuate access inequities – already common in this population (Kulik et al., 2011) – by pivoting to phone/virtual care without having a concurrent plan around addressing these very real barriers to access.

Finally, the need for in-person social connection – even in (or especially) during a pandemic – is something we must address. This theme is coming through in this survey, in our focus groups with providers (more on that in another post), and in emerging qualitative research on this topic. The detrimental impact of social exclusion, ensuing loneliness and potential influence on housing stability has been highlighted in pre-pandemic longitudinal research with youth who have experienced homelessness (see Dej & Schwan, 2019Kidd et al., 2016Thulien et al., 2018) and in The Roadmap for the Prevention of Youth Homelessness.

During this pandemic, as we work together to address the needs of young people who are experiencing or have experienced homelessness, we need to ensure we adapt our mental health and substance use services in a way that is equitable for all and recognizes the very real mental and emotional toll of ongoing social and economic exclusion.