Critical Time Intervention for Homeless People Making the Transition to Community Living: A Randomized Controlled Trial.

To help create an evidence base in Europe for effective interventions that improve the well-being of homeless people, we tested whether critical time intervention (CTI), a time-limited intervention developed to support vulnerable people during times of transition, is effective outside the United States. For this multicenter, parallel-group randomized controlled trial, 183 adults who were moving from shelters in the Netherlands to supported or independent housing were allocated to CTI or care-as-usual. The primary outcome was number of days rehoused, which was assessed by interviewing participants four times during a 9-month follow-up. Outcomes were analyzed with three-level mixed-effects models. The primary outcome did not differ between groups. CTI had a significant effect on family support and, for people experiencing less social support, psychological distress. Groups did not differ significantly on social support, fulfillment of care needs, quality of life, self-esteem, excessive alcohol use, or cannabis use. Because few participants were homeless at 9 months, more research is needed to establish whether CTI can prevent long-term recurrent homelessness. Given recent emphasis on informal support in public services and positive effects of CTI on family support and psychological distress, CTI is a fitting intervention for Dutch shelter services.

Critical Time Intervention for People Leaving Shelters in the Netherlands: Assessing Fidelity and Exploring Facilitators and Barriers.

International dissemination of evidence-based interventions calls for rigorous evaluation. As part of an evaluation of critical time intervention (CTI) for homeless people and abused women leaving Dutch shelters, this study assessed fidelity in two service delivery systems and explored factors influencing model adherence. Data collection entailed chart review (n = 70) and two focus groups with CTI workers (n = 11). The intervention obtained an overall score of three out of five (fairly implemented) for compliance fidelity and chart quality combined. Fidelity did not differ significantly between service systems, supporting its suitability for a range of populations. The eight themes that emerged from the focus groups as affecting model adherence provide guidance for future implementation efforts.

Psychometric properties of the consumer quality index to assess shelter and community care services.

BACKGROUND: Our aim was to design a valid and reliable consumer quality index (CQI) specifically suited to assess the experiences that homeless people, homeless youth, and abused women have with shelter and community care services. METHODS: A pilot CQI questionnaire was constructed on the basis of literature study, focus group discussions with clients, concept mapping by clients and shelter workers, and a pre-pilot study. The pilot questionnaire was completed by 762 clients using shelter facilities for homeless people, homeless youth or abused women. Psychometric and multilevel analyses were performed to optimize the instrument and determine its validity, reliability and discriminative power. RESULTS: The preparatory research had revealed seven primary focus topics, all of which were incorporated into the pilot questionnaire. Psychometric analyses resulted in four reliable scales, one of which applied only to clients in residential, day or night shelter programs. The final instrument consisted of 42 items for community care clients and 52 for clients using residential facilities, and day and night shelters; 32 and 42 such items pertained to client experiences. CONCLUSION: The consumer quality index for shelter and community care services (CQI-SCCS) is a valid, reliable instrument for assessing the quality of these services. It provides guidance to facilities in quality maintenance and improvement, and it is useful in determining quality differences in facilities for homeless people and homeless youth.

Effectiveness of case management for homeless persons: a systematic review.

We reviewed the literature on standard case management (SCM), intensive case management (ICM), assertive community treatment (ACT), and critical time intervention (CTI) for homeless adults. We searched databases for peer-reviewed English articles published from 1985 to 2011 and found 21 randomized controlled trials or quasi-experimental studies comparing case management to other services. We found little evidence for the effectiveness of ICM. SCM improved housing stability, reduced substance use, and removed employment barriers for substance users. ACT improved housing stability and was cost-effective for mentally ill and dually diagnosed persons. CTI showed promise for housing, psychopathology, and substance use and was cost-effective for mentally ill persons. More research is needed on how case management can most effectively support rapid-rehousing approaches to homelessness.

The effectiveness of critical time intervention for abused women and homeless people leaving Dutch shelters: study protocol of two randomised controlled trials.

BACKGROUND: One of the main priorities of Dutch organisations providing shelter services is to develop evidence-based interventions in the care for abused women and homeless people. To date, most of these organisations have not used specific intervention models and the interventions which have been implemented rarely have an empirical and theoretical foundation. The present studies aim to examine the effectiveness of critical time intervention (CTI) for abused women and homeless people. METHODS: In two multi-centre randomised controlled trials we investigate whether CTI, a time-limited (nine month) outreach intervention, is more effective than care-as-usual for abused women and homeless people making the transition from shelter facilities to supported or independent housing. Participants were recruited in 19 women's shelter facilities and 22 homeless shelter facilities across The Netherlands and randomly allocated to the intervention group (CTI) or the control group (care-as-usual). They were interviewed four times in nine months: once before leaving the shelter, and then at three, six and nine months after leaving the shelter. Quality of life (primary outcome for abused women) and recurrent loss of housing (primary outcome for homeless people) as well as secondary outcomes (e.g. care needs, self-esteem, loneliness, social support, substance use, psychological distress and service use) were assessed during the interviews. In addition, the model integrity of CTI was investigated during the data collection period. DISCUSSION: Based on international research CTI is expected to be an appropriate intervention for clients making the transition from institutional to community living. If CTI proves to be effective for abused women and homeless people, shelter services could include this case management model in their professional standards and improve the (quality of) services for clients. TRIAL REGISTRATION: NTR3463 and NTR3425.

Differences between homeless women and men before and after the transition from shelter to community living: A longitudinal analysis.

Social quality is the extent to which people are able to participate in social relationships under conditions which enhance their well-being, capacities and potential and enables them to shape their own circumstances and contribute to societal development. We assessed whether women in homeless shelters differed from men on social quality factors that constitute the quality of their daily life and whether factor scores changed at a different rate for women and men after shelter exit. Data were collected as part of a randomised controlled trial. In 18 shelters across the Netherlands, 183 participants were recruited between December 2010 and December 2012 and followed for 9 months. Adults were eligible if they were about to move from shelter to (supported) independent housing and their shelter stay had been shorter than 14 months. At baseline, women were significantly younger than men. They were more likely to have children, to have minor children staying with them, to be lower educated, to be unemployed and to have been victimised than men. Women had used more services and reported lower self-esteem, less satisfaction with health and empowerment and higher psychological distress. They were less likely than men to have used alcohol excessively or cannabis. We found no significant differences between women and men in changes over time on the social quality factors. As women were disadvantaged at baseline compared to men regarding many factors, we concluded that women in homeless shelters are a particularly vulnerable group. Moreover, an opportunity remains for shelter services to improve women's social quality during and after their shelter stay.

Factors Related To Depression and Post-Traumatic Stress Disorder in Shelter-Based Abused Women.

In this study, linear mixed-effects regression analyses were used to examine whether sociodemographic variables, abuse-related variables, and well-being variables were associated with symptoms of depression and post-traumatic stress disorder (PTSD) in abused women residing in shelters. Results pointed out that symptoms of depression severity were positively associated with migration background and the experience of physical abuse and negatively associated with self-esteem and social support. PTSD symptoms were positively associated with the experience of sexual abuse and negatively associated with self-esteem. Within women's shelters, staff could be sensitive to improving the social integration of women, especially those with a non-Dutch background, and strengthening the women's social networks and their self-esteem.

Stress regulation in adolescents: physiological reactivity during the adult attachment interview and conflict interaction.

The current study examined whether adolescents' attachment representations were associated with differences in emotion regulation during the Adult Attachment Interview (AAI; C. George, N. Kaplan, & M. Main, 1996) and during a mother-adolescent conflict interaction task (Family Interaction Task [FIT]; J. P. Allen et al., 2003). Participants were one hundred and fifty-six 14-year-old adolescents. Dismissing adolescents showed less interbeat interval (IBI) reactivity (indicating less stress) during the AAI than secure adolescents. However, during the FIT, dismissing adolescents showed more IBI reactivity. No differences in physiological reactivity were found between individuals with resolved or unresolved loss or trauma during the AAI or FIT. The results indicate that dismissing adolescents may effectively use a defensive strategy during the AAI but less so in direct conflict interaction with their attachment figure.

Subgroups of Dutch homeless young adults based on risk- and protective factors for quality of life: Results of a latent class analysis.

It is important to gain more insight into specific subgroups of homeless young adults (HYA) to enable the development of tailored interventions that adequately meet their diverse needs and to improve their quality of life. Within a heterogeneous sample of HYA, we investigated whether subgroups are distinguishable based on risk- and protective factors for quality of life. In addition, differences between subgroups were examined regarding the socio-demographic characteristics, the use of cognitive coping strategies and quality of life. A total of 393 HYA using shelter facilities in the Netherlands were approached to participate, between December 2011 and March 2013. Structured face-to-face interviews were administered approximately 2 weeks after shelter admission by trained research assistants. A latent class analysis was conducted to empirically distinguish 251 HYA in subgroups based on common risk factors (former abuse, victimisation, psychological symptoms and substance use) and protective factors (resilience, family and social support and perceived health status). Additional analysis of variance and chi-square tests were used to compare subgroups on socio-demographic characteristics, the use of cognitive coping strategies and quality of life. The latent class analysis yielded four highly interpretable subgroups: the at-risk subgroup, the high-risk and least protected subgroup, the low-risk subgroup and the higher functioning and protected subgroup. Subgroups of HYA with lower scores in risk factors showed higher scores in protective factors, the adaptive cognitive coping strategies and quality of life. Our findings confirm the need for targeted and tailored interventions for specific subgroups of HYA. Social workers need to be attentive to the pattern of risk- and protective factors in each individual to determine which risk factors are prominent and need to be targeted and which protective factors need to be enhanced to improve the quality of life of HYA.

The effectiveness of critical time intervention for abused women leaving women's shelters: a randomized controlled trial.

OBJECTIVES: To examine the effectiveness of critical time intervention (CTI)-an evidence-based intervention-for abused women transitioning from women's shelters to community living. METHODS: A randomized controlled trial was conducted in nine women's shelters across the Netherlands. 136 women were assigned to CTI (n = 70) or care-as-usual (n = 66). Data were analyzed using intention-to-treat three-level mixed-effects models. RESULTS: Women in the CTI group had significant fewer symptoms of post-traumatic stress (secondary outcome) (adjusted mean difference - 7.27, 95% CI - 14.31 to - 0.22) and a significant fourfold reduction in unmet care needs (intermediate outcome) (95% CI 0.06-0.94) compared to women in the care-as-usual group. No differences were found for quality of life (primary outcome), re-abuse, symptoms of depression, psychological distress, self-esteem (secondary outcomes), family support, and social support (intermediate outcomes). CONCLUSIONS: This study shows that CTI is effective in a population of abused women in terms of a reduction of post-traumatic stress symptoms and unmet care needs. Because follow-up ended after the prescribed intervention period, further research is needed to determine the full long-term effects of CTI in this population.

Fidelity of a strengths-based intervention used by dutch shelters for homeless young adults.

OBJECTIVE: In a cluster randomized controlled trial, this study aimed to investigate the effectiveness of and fidelity to Houvast (Dutch for "grip"), a strengths-based intervention to improve the quality of life for homeless young adults. METHODS: Fidelity was measured six months after professionals and team leaders at five Dutch shelters for homeless young adults finished their training in Houvast. Fidelity was measured with the Dutch version of the strengths model fidelity scale, which consists of ten indicators distributed across three subscales: structure, supervision, and clinical practice. A total fidelity score was composed by averaging the ten indicator scores for each facility. During one-day audits by two trained assessors visiting each facility, a file analysis (N=46), a focus group with homeless young adults (N=19), and interviews with the team leader and supervisor (N=9) were conducted. Professionals, supervisors, and team leaders completed questionnaires two weeks before the audit (N=43). In addition, an evaluation of the audit was conducted six months later. RESULTS: Although none of the five shelters achieved a sufficient total model fidelity score, median scores on caseload, group supervision, and strengths assessment were satisfactory. Each facility received a report with a set of recommendations to improve model fidelity. The evaluation showed improvements in use of the strengths assessment and personal recovery plans and in supervision. CONCLUSIONS: Facilities face several challenges when implementing a new intervention, and implementing Houvast was no exception. Learning experiences and possible explanations for the insufficient total fidelity scores are reported.

Remaining or becoming secure: parental sensitive support predicts attachment continuity from infancy to adolescence in a longitudinal adoption study.

In a longitudinal study with 125 early adopted adolescents, we examined continuity of attachment from infancy to adolescence and the role of parental sensitive support in explaining continuity or discontinuity of attachment. Assessments of maternal sensitive support and infant attachment (Strange Situation Procedure) were completed when infants were 12 months old. When the children were 14 years old, we observed mothers' sensitive support during a conflict discussion. The adolescents' attachment representations were assessed with the Adult Attachment Interview. Mothers of secure adolescents showed significantly more sensitive support during conflicts than did mothers of insecure adolescents. Overall, no continuity of attachment from infancy to adolescence was found. However, maternal sensitive support in early childhood and adolescence predicted continuity of secure attachment from 1 to 14 years, whereas less maternal sensitive support in early childhood but more maternal sensitive support in adolescence predicted children's change from insecurity in infancy to security in adolescence. We conclude that both early and later parental sensitive support are important for continuity of attachment across the first 14 years of life.

The concept of coherence in attachment interviews: comparing attachment experts, linguists, and non-experts.

Coherence is a central construct in attachment interviews. Nevertheless, the concept has never been the main focus of a study in the attachment field. The present study examined whether coherence in attachment interviews is defined differently by experts trained in attachment theory, by linguists, and by non-experts. The 72-item Coherence Q-sort (CQS) was used to determine the profile of a prototypical coherent interview. Results indicated that attachment experts could be reliably distinguished from the (combined) other groups: attachment experts emphasized quality and manner more than all other groups, linguists emphasized quantity and relevance more than attachment experts, and higher educated non-experts valued relevance more than attachment experts. Defining coherence in attachment interviews is thus more than just applying Grice's linguistic maxims; expertise in attachment theory is critical for defining interview coherence. Consequences for the coding of the AAI by non-attachment experts, as well as computer coding (im)possibilities are discussed.