Getting Help: Findings from Two World Cafés with Youth who Experience Homelessness

Studies indicate that youth who experience homelessness are more likely than their peers to have mental health and substance use concerns. The objective of this study was to investigate youth views of ideal services and service provision environments that facilitate help seeking. Data were collected from two World Café events in Canada where youth (n=14) were asked to discuss their experiences with housing, mental health and addictions services. The discussions were captured visually by a graphic recorder and on paper tablecloths that were drawn and written on by the youth. These visual data, along with field notes prepared by the research team, were analyzed. The findings indicated that barriers to help seeking included stigma, institutional distrust and fear, negative relationships, and the lack of self-awareness. Facilitators included positive therapeutic relationships, services with the capacity to offer care, and nonjudgmental environments. Youth wanted services that provide peer support, allow them to participate more in their care decisions, and use self-directed healing strategies. Service providers and policymakers should offer programming that facilitates youth access. They should consider the barriers that youth experience and seek to construct interventions for youth that are judgement free, confidential, and actively engage youth in their own care.


Introduction
Youth is an extremely important time where individuals typically learn to perform tasks and achieve life goals (e.g., educational and vocational) that are essential to social and economic success in adulthood. This period is often tumultuous, and those who experience adversity and trauma are at increased risk of poor outcomes in adulthood (Schilling et al., 2007). This is especially problematic for youth with exposure to Adverse Childhood Experiences (ACEs), which are defined as experiences that occur during childhood or adolescence that directly or indirectly cause harm (Hughes et al., 2017). Examples include abuse, neglect, housing instability, parental substance use, and family violence (Hughes et al., 2017). ACEs are significantly and positively associated with physical and mental health concerns, which include changes to immune, endocrine, and nervous systems, increased allostatic load (Danese and McEwen, 2012), early initiation of alcohol use (Dube et al., 2006), early child bearing (Hills et al., 2004), depression, drug use, and antisocial behaviour (Schilling et al., 2007), mental health concerns (Hughes et al., 2017), increased interpersonal and self-directed violence (Duke et al., 2010), obesity (Burke et al., 2011), homelessness (Lee et al., 2017), and learning and behavioural problems (Burke et al., 2011). Youth who experience ACEs in childhood are more likely to suffer from housing instability and mental health concerns.
Studies of youth with mental health concerns and housing instability find that many experience ACEs (Barnes et al., 2020;Shah et al., 2017). This has led researchers and practitioners to understand the value of trauma informed service provision (Muskett, 2014;Oral et al., 2016); however, guidelines for the implementation of these practices are not always clear (Muskett, 2014), and evidence-informed, youth-oriented services are not readily available (Oral et al., 2016). Some researchers argue that this is extremely problematic as it represents a missed opportunity to address the ongoing and recent impacts of socioeconomic adversity and trauma on youth (Metzler et al., 2017). The development of effective programming, services, and supportive and positive mentorship relationships can be extremely beneficial to youth with ACEs (Heerde & Hemphill, 2018). Despite this, many vulnerable youth remain resistant or unable to seek formal and informal supports (Evans et al., 2013;Labouliere et al., 2015;Rickwood et al., 2015). Barriers to seeking help include concerns about trust and confidentiality, stigma, and perceived loss of esteem from peers and adults (Gilchrist and Sullivan, 2006), denial, embarrassment, the belief that help seeking is a sign of weakness or failure, and youth's assumption that nothing can be done to help (Moskos et al., 2007). Research finds that youth benefit from connections with formal and informal supports, which provide them with access to supportive adult mentorship (Timpe & Lunkenheimer, 2015). Youth who experience homelessness and mental illness often have weak or non-existent ties with family and/or positive adult mentors (Whitbeck, 2017). This, coupled with reluctance to access formal supports, places these youth at risk of negative outcomes.
The barriers that youth face when they think about or attempt to access support for mental health and substance use are multifaceted and complex. Research on high school aged youth finds that youth are concerned about confidentiality and trust (Wilson et al., 2008). Additional barriers experienced by youth are stigma (Zartaloudi & Madianos, 2010), a lack of transportation (Francis et al., 2006;Murry et al., 2011), low mental health literacy, problems recognizing symptoms, and a preference for self-reliance (Gulliver et al., 2010). Male youth experience significant barriers to help seeking (Yousaf et al., 2015), which include incongruency between help seeking intentions and behaviours, lower emotional competence, fear of stigma, and negative beliefs about help seeking (Rickwood et al., 2015). Research with Black, male foster care alumni concludes that young men's need to appear in control of their own emotions is a large barrier to help seeking (Scott et al., 2015). Scholars argue that the desire to exude emotional control is a key tenant of traditional masculinity, which prevents younger males from seeking help (Powell et al., 2016;Yousaf et al., 2015).
The literature on youth help seeking behaviour for housing concerns is far more limited than that on mental health and substance use (Crosby et al., 2018). However, mental health concerns and housing instability in youth are often connected (Collins & Barker, 2009) and youth may require a variety of different services to promote stability (Davies & Allen, 2017;Hughes et al, 2010). Further, youth with the most severe mental illnesses are the least likely to receive treatment or help (Hughes et al., 2010), which is a significant barrier to recovery and housing stability.
Although research on barriers is robust, research on facilitators to youth engagement with services and supports is limited. In their systematic review of youth help seeking behaviour, Gulliver et al. (2010) note that research on facilitators is much more restricted than that on barriers. Rickwood et al. (2015) also conclude that researchers must learn more about factors that facilitate long-term youth service engagement. Common facilitators identified in the literature include youth's success with past efforts to seek help (Gulliver et al., 2010), mental health literacy, and supportive social influences (Rickwood et al., 2015). Parents often act as supportive social influences for youth, as they provide advice and connection to services and resources (Bates, 2010); however, some youth, such as those experiencing homelessness, do not have supportive relationships with parents. These youth often have histories of ACEs, which are associated poor mental health and housing outcomes (Davies and Allen, 2017).
This study fills an important gap in the literature, as it explores youth's perceptions of services for housing, mental health, and addictions in Hamilton, Ontario and on Prince Edward Island. These youth all have lived experience of adversity, which includes housing instability, mental health concerns and/or addictions.
The objective of this paper is to investigate youth's views of ideal services and service provision environments that facilitate help seeking.

Community-Based Approach
This research used a community-based approach (CBR). CBR actively engages community members and stakeholders in the research process (Suarez-Balcazar & Harper, 2014). In doing so, the researchers benefit from the contribution of community members and their knowledge and they increase their capacity to produce relevant research with direct impacts (Suarez-Balcazar & Harper, 2014). Further, these relationships are often valuable for partners who gain research capacity through participation in the process (Suarez-Balcazar & Harper, 2014). CBR is typically designed to answer questions of interest to partners and the findings are often useful for both the researchers and the partners.
CBR uses a collaborative approach to involve people with lived experience of an issue of interest in all parts of the research process (Viswanathan, 2004). However, this can pose a challenge to researchers who wish to establish partnerships at the outset of their research (for a discussion of challenges, see Dedding et al., 2020). Further, good CBR partnerships take time to establish, as they require familiarity and trust (Lawson, et al., 2015;Suarez-Balcazar & Harper, 2014). This study was conducted in the City of Hamilton in Ontario, Canada, and the province of Prince Edward Island (PEI). Hamilton and PEI were chosen as the sites for this study as the research team had partnerships with youth organizations in each locale who were able and willing to participate in the study's conception, design, planning, recruitment, data collection, and analysis. Trust and familiarity between the research team and community organizations predated the present study.
The main partners in this study were the Street Planning Youth Collaborative (SPYC) in Hamilton and the Canadian Association for Mental Health (CAMH) in PEI. The organizations were approached separately for initial discussions and both wanted to better understand youth service engagement and needs. They wanted youth to share their perceptions of services for mental health and housing in non-threatening, informal, open environments. These initial discussions led to the development of two separate World Café research events. CAMH and SPYC facilitated connections with other youth organizations who collaborated on the study. These organizations assisted with recruitment and provided feedback on the study design, world café questions and on the logistics (e.g., locations, room set-up, activities, participant remuneration) of the events.

World Café Research Events
The World Café (Brown & Isaacs, 2005) is an innovative method, which is designed to interactively engage individuals in discussions on meaningful and challenging questions. It is modelled after Appreciative Inquiry, which is a research design that emphasizes the creation of positive experiences that foster mutual creativity (Emlet & Moceri, 2012). The World Café approach facilitates idea exchange in safe settings. The main goal is to blend knowledge and experience of participants into mutual learning. Conversations are enabled by trained facilitators, called hosts, who help move conversations from the personal, to the collective and present moment, to the future (Brown & Isaacs, 2005). This approach is used to explore service needs and perceptions in other vulnerable populations (Johnson et al., 2018;Wright et al., 2019). This approach was particularly appropriate for the present study as it provided youth with a safe and engaging environment to collectively explore their experiences, which then moved toward the collective visualization and imagination of services and spaces to meet their needs.
The research team held two World Café events to understand youth experiences of housing and mental health services. The first World Café was held on June 20 th , 2015 in Charlottetown, PEI and the second was held in Hamilton on June 27 th , 2015. The cafés were held at youth centres that were accessible and known to local youth. Both locations were considered youth friendly spaces that were identified by community partners as safe spaces for youth.

Recruitment
The research team worked with the community partners to distribute flyers with information about the World Cafés and contact information. Youth who were interested in participating contacted the research coordinator via phone, text message, or email. The research coordinator screened youth and eligible youth were asked to participate in the study. If youth did not want to contact the study team directly, they could consent for a staff member at a community partner organization to share their contact information with the research coordinator. In these instances, they also empowered staff to share their age and housing status with the research coordinator. With their consent, youth who signed up to participate in the World Cafés were provided with a reminder call or text messages prior to the events.
Inclusion criteria were youth who were unhoused in the last year or who were worried about being unhoused. This included youth who were absolutely homeless, hidden homeless, in institutional care, or precariously housed. Although we did not initially seek youth with mental health or substance use concerns, discussions during the cafés reinforced aforementioned findings in the literature that precariously housed youth also have histories of ACEs, mental health concerns, and substance use. In Hamilton, youth was defined as 18-24 years of age, whereas in PEI it was defined as 16-27 years of age. The variation in ages is a result of differences in ages of the youth served by the agencies in each area. Youth were excluded if they had active psychosis, could not communicate proficiently in oral and written English, or if they presented as intoxicated at the events. Fourteen youth attended and participated in each of the World Cafés (n=28).

Data Collection
Youth were welcomed to the cafés by greeters, were offered light refreshments, and were asked to choose a table to join. The tables were covered with paper tablecloths and each had a variety of coloured pencils, markets, pens, and candies. The cafés began with an icebreaker activity with youth sitting at tables with 4 or 5 participants. The rest of the day was structured as a series of 20-minute conversations with breaks for comfort and food. Around noon, the youth were invited to share in lunch together. A research team member, trained as a World Café facilitator (FIM), led both cafés. A trained World Café graphic recorder captured images from the conversations. Each café had a trained social services worker in attendance to provide onsite to support for youth who required assistance.
The research team, in collaboration with youth representatives and community partners, developed questions for the café conversations (see Table 1). There were three question rounds, divided into two 20-minute conversations each. Participants engaged in three sets of conversations based on the questions provided in Table 1 with two rounds of conversations per set of questions. After the first conversation in round one, all but one youth at each table were asked to move to a different table to discuss the same questions with new people. One participant remained at each table to tell new table participants what was previously discussed. This procedure was followed for each conversation in all three rounds. To facilitate discussion at each table, paper tablecloths were provided. Youth were encouraged to write down or draw reactions, thoughts, and feelings on the paper tablecloths during the conversations. After two rounds of conversation for each set of questions, all participants came together to "harvest main themes from the smaller table discussions. The idea [is] to harvest the group's collective thinking and make their ideas visible so people [can] see new connections" (Brown & Isaacs, 2005 :141).
All participants received a $25 Visa gift card as compensation and participation certificates. Community partners in Charlottetown organized complimentary transportation to and from the café for all interested youth. Bus tickets were provided to youth in Hamilton who required transportation.

Ethics Statement
This research was approved by the Research Ethics Board at [removed for anonymization]. Participants provided verbal consent before the café began. In this exercise, we are asking you to co-create your own scenarios thinking about the following questions. If it helps, you can think about your own experiences. Come up with a person. Name? Age? Gender? Gender identity?
• Where is this person living?
• Who is part of their support system?
• Is this person going to school?
• What risky behaviors are they doing?
• What health or mental health problems do they have? • Are they in trouble with the police?
• What is going on in their relationships with peers, friends, partners? • What do they do to cope?
• What do they want next? What are their goals? • How do they feel? • Why do they want help? Now create a space and a place for this person to get help. What steps do you think this person could take to get help in an ideal world? (Be as wildly creative about this as you wantwhat did it look like, sound like, what was the space like, what was in the space (e.g., pets).

Analysis
The World Café method typically captures knowledge through tablecloth drawings, and/or graphic recordings collected during the table conversations and the harvest. The research team collected visual data from the tablecloths (sketches and words written by the youth) and graphic 'snippets' captured by a graphic recorder. Themes from the larger group discussions during the harvests were recorded on large murals. The words of youth that were captured on snippets, tablecloths and graphic recordings were analyzed and included throughout the research findings section.
The analysis began with the research team meeting to collectively summarize the visual data using words. The words were placed into an MS Excel spreadsheet. Each team member then reviewed the spreadsheet individually and then the team met on multiple occasions over the course of three months to discuss the themes that were individually identified. Collectively, data were classified by their reference to barriers and facilitators to youth help seeking. A third larger theme of visions of ideal services was constructed to house data that referred to youth's discussions of what they wanted to see in services. Data from each café were analyzed separately; however, significant overlaps in themes emerged in the data from the two locations. The team's discussions led to the creation of various subthemes in the data. The subthemes are presented under the main themes of barriers to help seeking, facilitators to help seeking, and youth wants below.

Results and Discussion
This combined results and discussion section presents barriers to help seeking, service engagement and care. Facilitators to help seeking and youth's vision for ideal services and spaces are presented together, as they both provide insights into mechanisms for youth engagement. To discuss implications for service delivery for youth who experience homelessness and mental health concerns and/or addictions, the authors integrate the findings of the present work with findings from previous literature.

Barriers to Help Seeking, Service Engagement, and Care
Youth spoke of barriers they experienced when they tried to access supports for housing, mental health, and substance use. They also discussed the reasons why they did not seek help for these concerns. These barriers provide fundamental background information for the subsequent analysis and discussion of facilitators to help seeking and youth's ideal service environments. The barriers that emerged in the data are summarized in Table 2.

Stigma
The youth described actual and perceived stigma as barriers to seeking help. They noted that they were afraid of being judged, disrespected, and labelled. One of the murals ( Figure 5) captured this: "Asking for help is seen as weak. Don't want to face the stigma of seeking help." Youth were concerned that they would experience stigma and its negative consequences if they sought treatment or help for substance use. Youth in PEI were particularly concerned that they would lose employment or their children if the disclosed substance use (see Table 2). They were worried that this disclosure would negatively impact their families' perceptions of them. This was a barrier to asking for help from family members and from formal service providers. These findings agree with previous research that finds stigma associated with substance use negatively affects help seeking (Kulesza et al., 2013).
Youth described the judgement and stigma they experienced when they interacted with supports for mental health. One of the murals (see Figure 5) captured this: "People think mental health means stupid." They did not like being viewed as a patient and desired acceptance. They felt that they were judged for past actions and that service providers did not understand their mental health concerns and the impacts of mental illness on their actions and lives (see Table 2). These findings reflect what is known from previous research on youth who experience homelessness. Morisseau et al. (2020) found that stigma related to mental health and housing status was detrimental to youth. Stigma placed already vulnerable youth at increased risk of poor mental health (Kidd, 2007). Youth cited stigma as a reason for not seeking help for housing and mental health concerns, which created dual disadvantage and made recovery and housing stability less likely (Morisseau et al., 2020).
Research indicates that perceived and internalized stigma are major barriers to youth help seeking (Clement et al., 2015). The youth in the present study discussed stigma from family members, peers, and care providers. As indicated in Table 2 and in Figure 5, youth felt judged and disrespected when they accessed services. They worried about being made fun of and felt stupid, labelled, judged, and belittled for accessing support for mental health. This finding is reflected in the literature on barriers to help seeking (Clement et al., 2015;Heflinger & Hinshaw, 2010).
Although most of the youth experienced stigma, the LGBTQ2S+ youth talked about gender or sexuality-based stigma and name calling from family and friends (see Table 2). Previous research corroborates this finding and indicates that LGBTQ2S+ youth who experience poverty, housing instability, and mental health concerns also face the impacts of intersecting stigmas, which poses barriers to seeking formal and informal assistance for housing and mental health (Abramovich, 2017;English et al., 2018;Veale et al., 2017). The present research reinforces this finding, as LGBTQ2S+ youth who participated in the cafés experience stigma and name calling when they reached out for help.

Institutional Distrust and Fear
In the second round of conversations, youth were asked about what prevents them from seeking help. The youth responded by speaking about their experiences when they engaged with formal institutions. They were particularly vocal about hospitals and vulnerability, and they found it difficult to build rapport with healthcare providers in hospitals. As illustrated in Figure 6, youth stated there was a "Lack of honesty. Why am I here? How long? …[I] felt coerced, forced to get help." Youth were also concerned that there would be negative consequences, such as the removal of children from their custody, when they were institutionalized. When treated for psychiatric concerns or addictions at hospitals and inpatient programs, youth felt that staff did not provide them with enough information about their condition and treatments.
Although studies find that institutional care for youth with mental illness can be as effective as community-based care (De Swart et al., 2012), there is limited research on youth perspectives of institutional care (Polvere, 2014). Prior research that does include youth perspectives indicated that youth were wary of institutionalization for mental health concerns (Gulliver et al., 2010). In her qualitative study of youth, Polvere (2014) found that they felt institutional reform was necessary. They were resistant to many institutional practices that they perceived as inappropriate and they often only complied with practices to avoid physical restraint, and to expedite discharge. The youth in the present study were concerned that they would be forced into receiving treatment if they were hospitalized for mental illness. They were also worried that treatments could result in "worse" mental health. Youth noted that knowledge of one's rights, self-advocacy, and independence were important for youth who spend time in institutional mental health settings. Polvere's (2014) findings also indicate the importance of self-advocacy for youth who interact with mental health institutions.

Relationships
Relationships were discussed by youth as positive contributors to help-seeking and care, but they were also described as barriers. Youth were concerned with the opinions of friends, family members, and peers. They were worried that they would be talked about, made fun of, or looked down on for accessing support for housing, mental health and/or substance use. They did not want their peers to know that they had received formal help. They discussed their experiences when they reached out to peers for assistance. Some found this to be helpful, whereas others said that peers had given them "bad" or misinformed advice (see Table 2). One of the snippets (see Figure  1) captures a youth's description of their need to remove themselves from a relationship that was not positive: "I can't be focusing on depressing things and my recovery. We're taking a break." The other youth in the cafés also discussed their need to leave relationships that were not conducive to their mental health, housing stability, and/or recovery.
The present findings are consistent with the literature on youth help seeking, which indicates that family and peer stigma are significant barriers (Chandra & Minkovitz, 2007). Pisani et al. (2012) found that only 15% of youth with recent suicidal ideation told an adult and sought their assistance. Although mental health concerns themselves limited help seeking (Wilson et al., 2007), researchers also found that the fear of negative reactions from family members and peers dissuaded youth (Chandra & Minkovitz, 2007). Pisani et al. (2012) argued that culture on stigma, mental health, and seeking assistance must change to encourage youth to seek help for mental health concerns.
Youth in Hamilton described relationships with some service providers as a barrier. They said that they felt that they were viewed as "not deserving of help." This was captured in one of the murals (see Figure 5). They did not feel that they had trusting relationships with their service providers and they wanted more information about their treatment (see Table 2). One of the snippets (Figure 3) includes a statement by a youth who said, "I don't need them [service providers] to force me to do their idea of help." They worried that their treatment providers would make things worse for them, which suggested that they did not trust many of the service providers they saw.

Self-Identity and Self-Awareness
The youth saw addiction and drug use and its effects on self-identity as barriers to seeking help. They noted that drug addiction made them view themselves as being okay when they were not. Some of the youth noted that they did not recognize that they had a "problem" and that this lack of recognition prevented them from seeking supports that could have assisted with recovery from mental illness and addictions. Figure 5 displays a quote from one of the youth: "Our minds are the best producers of bullshit and we are the first in line to buy it." This youth described their own thoughts about their mental health and substance use as an obstacle to recovery. Similarly, other youth noted that they were not always able to acknowledge their needs. They described this as "lying to yourself about your problems." The youth described their inability to recognize or acknowledge that they needed help as a barrier. They said they were concerned about "sticking out" or being perceived as different, so they relied on themselves to fix their own problems instead of seeking support. Self-judgement and the desire not to speak about themselves to others prevented them from reaching out for support.
These findings were consistent with research findings that youth who tried to solve their own problems to exercise self-reliance or evade being seen as different often avoided professionals and other supportive individuals (Gulliver et al., 2010). This is problematic, as youth were not always aware of their treatment and/or housing needs (Rickwood et al., 2005). Further, an overemphasis on self-reliance can restrict access to professional supports (Labouliere et al., 2015), which can contribute to further instability and experiences of poor mental health. Lying to yourself about problems; self-reliance; keep to yourself; don't want to stick out or be different *Youth spoke of relationships and self-identity as barriers to help seeking, but they also described some of their relationships and strong self-awareness/identity as facilitators to help seeking, service engagement, and care (see Table 3).

Facilitators to Help Seeking & Ideal Service Environments
Youth described situations where they successfully received help. They were asked to describe what they would like to experience when they engage with services and to make recommendations for formal and informal supports that meet the needs of youth. The data on facilitators to help seeking and ideal service environments are summarized in Table 3.

Self-Directed Healing Strategies
Youth in this study viewed self-reliance as both a barrier and a facilitator to receiving assistance with mental health, housing, and addictions. As noted above, self-reliance was problematic for some youth. However, others noted that they successfully employed self-directed strategies. These youth noted that self-reliance requires honesty with oneself. This reinforced the previously stated finding that lying to oneself was a barrier to help seeking. The youth who benefited from self-directed strategies had a desire to restore relationships and rebuild trust with family members and friends. They also wanted to lead healthier lifestyles and meet educational and/or vocational goals (see Table 3). To do this, they said that they needed to focus on themselves and that they needed to be positive, as "depressing things" were not conducive to recovery. They employed a variety of self-help and self-management strategies which included listening to music and spending time with pets. One of the snippets (see Figure 2) captured one youth's need for "stability, honesty, friendship, and [her] dog." Other self-help strategies were riding motorcycles and engaging in activities that allowed for creative expression (e.g., music and other art). Recent research finds that youth can benefit from engagement with non-traditional treatment methods which are structured around their interests (Spinazzola et al., 2011;Steffanini et al., 2015).

Positive Therapeutic Relationships
The youth talked about the importance of positive professional and informal therapeutic relationships. They described what they wanted to see in positive, therapeutic relationships with service providers (see Table 3). They wanted access to providers who spoke with respect and were honest and non-judgmental. They wanted providers they could trust (see Figure 4) and who were consistently available and reliable. To them, this meant working with open minded providers for longer periods of time. Research indicates that youth who had negative past experiences with service providers were less likely to engage with services when they needed them (Lindsey et al., 2013). Conversely, youth who form trusting, respectful relationships with service providers are more likely to reach out for help when they are in need (Cortis, 2012).
The youth wanted access to positive relationships with peers who had experienced similar struggles as themselves (see Figure 5). They wanted to draw knowledge and hope from peers who had experienced vocational, housing, and recovery successes. The youth noted that support groups may be useful to connect them with peers to engage with and learn from. Although the literature in this area is limited, research finds that online, peer support groups may be an effective youth mental health intervention; however, the evidence is still largely inconclusive (Ali et al., 2015;Naslund et al., 2016). Online and social media delivery of peer support should be explored further in future studies.
Older research concludes that supports provided by untrained or informal sources may not be helpful for youth (Offer et al., 1991;Rickwood et al., 2005). However, other studies highlight the value of peer-driven supports and find that they provide comparable, if not better, outcomes (Landers & Zhou, 2011;Repper & Carter, 2011). Relationships that are natural and informal are found to be beneficial to youth who strive to live independently (Spencer et al., 2010). Informal support from youth with lived experience provides access to individuals to whom youth can relate. It is essential that these relationships are built on mutual trust, understanding, and acceptance (Davidson et al., 2013). When strong relationships are built, peers can empathize with youth and provide them with hope for the future. This is particularly important for youth who are referred to as "difficult to reach" (Davidson et al., 2013: 124).

Space & Capacity
The youth desired additional treatment spaces and services without waitlists that provided immediate access to supports (see Figure 6). Youth wanted more shelter beds, as they found shelter access difficult. They also perceived a need for more frontline staff, so they could access help when needed. One of the youth stated that a barrier was: "The time it takes to get help. Months. It has to be sooner." They felt that staff were often overburdened, and they often had no effort left to give their clients (see Table 3). Conditions in the social, psychological, health, and community services sectors have led to experiences of burnout and compassion fatigue in workers (Rossi et al., 2012). The youth in the present study wanted workers who were physically and mentally available and they recognized that systemic issues, such as underfunding and growing demand for services, contributed to challenges with sector/provider capacity.
The youth also spoke of the need for low-barrier services that were easy to access (see Table 3). They wanted assistance with transportation to services (see Figure 5), youth-friendly spaces with access to nature, spaces that allow pets, and spaces where they can be relaxed and at ease. Rhoades et al. (2015) found that 23% of the youth in their study of homelessness in Los Angeles owned pets. Pet ownership creates service, shelter, and housing barriers for youth. However, it also provides youth with emotional, social, and psychological benefits (Rhoades et al., 2015). The youth in the present study called for access to spaces that were conducive to their lifestyles, which for some meant spaces that allowed pets.

Services that do not Discriminate
The youth wanted access to services that did not discriminate based on gender or sexual orientation. They wanted access to LGBTQ2S+ friendly spaces with all gender bathrooms. They wanted to be asked about gender and did not want others to assume their gender. They noted that gender should not be a "weird" thing; gender diversity should be normalized. They stated that services should be available to all those who need them, regardless of gender identity and/or sexual orientation (see Table 3 and Figures 5 and 6).
The youth noted that many support services, especially in the housing sector, were segregated by sex and/or gender. As noted in Table 3, youth wanted services that did not discriminate or segregate. This was also captured by the graphic artist in Figures 5 and 6. One youth said: "Gender shouldn't matter! It has nothing to do with it. We are all human beings. EQUAL. PERIOD" and "if they [service providers] assume [your gender] they're not respectful…If you don't know, ASK!" Research finds that LGBTQ2S+ youth disproportionately experience mental health, substance use, and housing concerns (Abramovich, 2012;Choi et al., 2015). This is especially problematic for LGBTQ2S+ youth who live with poverty. Robinson's (2018) ethnographic study of 40 LGBTQ2S+ youth finds that family rejection is a pathway to homelessness; however, rejection is often fueled by preexisting family tensions that arise from instability and poverty. These youth experience confounding adversity from histories of poverty and family rejection.

Recommendations
The findings of this study have important implications for service providers and policy makers who work with youth that experience mental health and/or substance use concerns and housing instability. The recommendations are as follows: Ensure youth-focused service environments are designed to provide trusting therapeutic relationships: The findings indicate that youth want to be treated with dignity and respect. They fear stigma and want relationships that are respectful and honest. They want to be understood and heard. These findings may seem intuitive; however, the youth discussed a lack of dignity in relationships as major barriers to their willingness to access support when it is needed. Systems level recommendations include the establishment of peer supports in institutional settings that assist vulnerable youth with self-advocacy.
Provide services that are non-judgmental and conducive to protecting youth's right to privacy: In the present study, stigma was a prominently discussed barrier to youth seeking help from both formal and informal supports. This study uncovered the need for service providers to assist youth with finding care that helps them avoid stigma. Services and interventions should be designed to protect youth from being identified by community members who may hold stigmatizing views of those who seek help. For example, services could be placed in locations that do not put youth at risk of being identified by peers and family members. Virtual supports may offer accessible alternatives to youth who desire more confidentiality. Although research on virtual supports for youth is still in its infancy, Evans et al. (2013) find that text-based supports for youth in crisis increase help seeking. The recent migration of in-person services to virtual formats during Covid-19 should produce an abundance of evidence on the efficacy of these types of support. At the systemic level, more work is needed to normalize mental health care and to destigmatize substance use and homelessness.
Involve youth in their care decisions: Like Gulliver et al. (2010), the present authors argue that youth programming must consider youth's desire to be self-directed and involved in their care, while providing access to professionals, resources, information, and services that support their needs and development. In doing so, service providers may consider exploring programs that allow youth to focus on goals, while they engage with their own interests and healing strategies. For example, research indicates that various forms of non-traditional therapies, such as, pet-facilitated therapy, which involves the use of pets or as accompaniments to traditional therapies, promote positive mental health outcomes in youth (Stefanini et al., 2015).
Provide access to peer supports & focus on building trusting relationships with all persons who provide support: Youth want to hear from others who have had similar experiences with mental health, substance use, and housing instability. This could involve providing youth with access to trained peer support workers who can truly empathize and relate to vulnerable youth. The literature indicates that mentorship relationships are most beneficial when they are natural and informal (Spencer et al., 2010); therefore, running social programs or fun activities for youth who are in various stages of their journeys could facilitate natural connections.
Service providers should focus on building rapport with youth clients and could have conversations about confidentiality, respect, and trust. The youth identified continuity of care as fundamental to building and maintaining trusting relationships. Persons and services that provide formal and informal supports should attempt to establish long-term relationships between youth and adults who they can trust.
Increase system capacity to provide supports to youth: Increased capacity (e.g., additional space, staffing, and financial resources) could ensure that youth receive timely supports, which should decrease the amount of harm they experience during a critical developmental stage of life. The findings also indicate a need for additional services that support LGBTQ2S+ youth. Constructing welcoming and inclusive spaces that provide youth services could encourage more youth to access these services. As noted in the present study, designating all genders washrooms could help youth feel more comfortable. Service providers may try to solicit youth input on their current or planned spaces to construct places that are more appealing to youth.

Strengths and Limitations
This study benefited from the use of the World Café Method which is a participatory approach to knowledge creation. As part of the World Café approach, the research team worked closely with youth and agencies that support youth to develop the research questions to ensure they would resonate with the participants and provoke meaningful conversation. Further, engagement of a graphic recorder to visually capture the table and harvest conversation is a unique aspect of the World Café. The use of a novel approach to data collection engaged youth in collective thought on their housing and mental health needs. This is transformative, as qualitative data on youth needs often reflect individual realities that are captured in interviews. The community-based approach built on strong established community partnerships within each location and allowed for the integration of feedback and perspectives of the community into the research process.
This study experienced some limitations. The data were collected in a group setting, which may have inhibited quieter youth from discussing their experiences and views. This research engaged a relatively small number of youth; therefore, the experiences are not generalizable to all youth. However, as with qualitative research, the aim of the World Café method is not to produce generalizable evidence, but rather to explore collective realities. The two specific locations chosen for the café vary greatly in geography and size, but they both have well-developed resources for youth that were discussed and explored. The similarities in experiences of youth despite the differences in geographies indicates a shared reality amongst these youth that warrants further exploration. Future research should test the applicability of these findings to youth in other parts of Canada and in other countries.

Conclusion
Youth in this study experienced significant barriers to help seeking. Barriers included stigma, fear and distrust of institutions, negative experiences with service providers, friends, and family members, and challenges with self-identity and self-awareness. The youth participants generated some recommendations that could be implemented to improve their experiences. For example, being able to participate in self-directed healing strategies; have trusting therapeutic relationships with providers; and access to peer support workers. Youth wanted increased capacity in shelters and service agencies to meet housing and therapeutic needs and they wanted services that were low-barrier, LGBTQ2S+ and youth friendly. Service providers, policy makers, and adults who interact with vulnerable youth should consider the needs and desires of youth when they attempt to engage them with support and treatment options.