David E. Pollio

Factors associated with trauma and posttraumatic stress disorder among homeless youth in three U.S. cities: The importance of transience†

Homeless youth experience disproportionately high rates of trauma and posttraumatic stress disorder (PTSD). This study examined correlates of trauma and PTSD among homeless youth with a focus on the impact of homeless culture, substance addiction, and mental health challenges. Homeless youth (N = 146) from Los Angeles, California, Denver, Colorado, and St. Louis, Missouri, were recruited from organizations providing services to homeless youth using comparable methods. Results indicate that 57% of respondents had experienced a traumatic event and 24% met criteria for PTSD. A multinomial logistic regression model revealed greater transience, alcohol addiction, mania, and lower self-efficacy predicted PTSD whereas trauma exposure was associated with alcohol addiction only. Findings have implications for screening and intervening with traumatized homeless youth across service settings.

Short-Term Outcomes for Youth Receiving Runaway and Homeless Shelter Services

Objective: Few studies have assessed the outcomes of runaway/homeless youth that seek assistance from shelter or crisis services, which would provide much needed documentation of intervention effectiveness and point to new directions for service provision. The goals of the current study were to: (1) assess short-term outcomes among runaway/homeless youth using emergency shelters and crisis services and (2) compare short-term outcomes achieved by runaway/homeless youth in crisis shelters with similar youth using other, longer-term treatment modalities. Method: The study sampled 261 youth using runaway/homeless shelters from four midwestern states at intake and six-weeks postdischarge and 47 high-risk youth using longer-term services at intake and six weeks postintake; ten key outcome variables were assessed. Results: Every outcome variable demonstrated improvement postintervention: days on the run, school suspension and/or detention, and sexual activity decreased; perceived family support and self-esteem increased; and youth were more likely to be currently employed and less likely to have been fired. In comparing runaway/homeless crisis shelter users with day treatment users on the ten outcome variables, there were no significant differences across any of the outcome variables. Conclusions: Despite limitations, the research provides evidence for the short-term effectiveness of crisis shelter services for runaway/homeless youth.

Correlates of Street-Survival Behaviors in Homeless Young Adults in Four U.S. Cities

This study assessed the prevalence and correlates of behaviors used by homeless young people to survive on the streets. Survival behaviors include prostitution, selling blood or plasma, dealing drugs, stealing, and panhandling. One hundred ninety-six homeless young adults from 4 metropolitan areas-Los Angeles, CA (n = 50); Austin, TX (n = 50); Denver, CO (n = 50); and St. Louis, MO (n = 46)-participated in individual, semistructured, face-to-face interviews. Researchers predicted that youth transience would be related to high rates of survival behaviors. Multivariate logistic regression was used to test a model predicting relationships between survival behaviors and transience, employment, substance use, and social support. Young adults who were transient, unemployed, drug-addicted, and reliant on peers for help were more likely to use these survival behaviors. In addition, among the transient subsample, being White, more reliant on peers for help, more transient, and having been victimized were associated with high use of these survival behaviors. Identification of the environmental and demographic factors associated with survival behaviors suggests that there may be value in combining harm-reduction strategies with efforts to reduce the transience of homeless young adults.

Employment Status and Income Generation Among Homeless Young Adults Results From a Five-City, Mixed-Methods Study

This mixed-methods study identified correlates of unemployment among homeless young adults in five cities. Two hundred thirty-eight homeless young people from Los Angeles (n = 50), Austin (n = 50), Denver (n = 50), New Orleans (n = 50), and St. Louis (n = 38) were recruited using comparable sampling strategies. Multivariate logistic regression results indicate that homeless young adults were more likely to be unemployed if they had been on the streets longer, currently lived on the streets, earned an income from panhandling, and were addicted to drugs. Quantitative findings are expanded on with focus-group data from a group of homeless young people in Los Angeles regarding their challenges in locating and maintaining employment. Employment-related barriers for this population include prior homelessness, geographic transience, previous felonies, mental illness, and addiction. Findings suggest that homeless young adults’ employment status and use of specific income-generating activities may be influenced by demographic, environmental, and geographic contexts.

Trauma Exposure and Posttraumatic Stress Disorder Among Employees of New York City Companies Affected by the September 11, 2001 Attacks on the World Trade Center

OBJECTIVE Several studies have provided prevalence estimates of posttraumatic stress disorder (PTSD) related to the September 11, 2001 (9/11) attacks in broadly affected populations, although without sufficiently addressing qualifying exposures required for assessing PTSD and estimating its prevalence. A premise that people throughout the New York City area were exposed to the attacks on the World Trade Center (WTC) towers and are thus at risk for developing PTSD has important implications for both prevalence estimates and service provision. This premise has not, however, been tested with respect to DSM-IV-TR criteria for PTSD. This study examined associations between geographic distance from the 9/11 attacks on the WTC and reported 9/11 trauma exposures, and the role of specific trauma exposures in the development of PTSD. METHODS Approximately 3 years after the attacks, 379 surviving employees (102 with direct exposures, including 65 in the towers, and 277 with varied exposures) recruited from 8 affected organizations were interviewed using the Diagnostic Interview Schedule/Disaster Supplement and reassessed at 6 years. The estimated closest geographic distance from the WTC towers during the attacks and specific disaster exposures were compared with the development of 9/11-related PTSD as defined by the Diagnostic and Statistical Manual, Fourth Edition, Text Revision. RESULTS The direct exposure zone was largely concentrated within a radius of 0.1 mi and completely contained within 0.75 mi of the towers. PTSD symptom criteria at any time after the disaster were met by 35% of people directly exposed to danger, 20% of those exposed only through witnessed experiences, and 35% of those exposed only through a close associates direct exposure. Outside these exposure groups, few possible sources of exposure were evident among the few who were symptomatic, most of whom had preexisting psychiatric illness. CONCLUSIONS Exposures deserve careful consideration among widely affected populations after large terrorist attacks when conducting clinical assessments, estimating the magnitude of population PTSD burdens, and projecting needs for specific mental health interventions.

Estrangement factors associated with addiction to alcohol and drugs among homeless youth in three U.S. cities

Substance use is highly prevalent among homeless, street-involved young people. Societal estrangement is often associated with substance use, particularly among this population. The current study sought to identify four domains of social estrangement (disaffiliation, human capital, identification with homeless culture, and psychological dysfunction) in relation to alcohol and drug addiction. Homeless young adults were recruited from three disparate urban areas: Los Angeles, CA (n=50), Austin, TX (n=50) and St. Louis, MO (n=46) using comparable research methods and measurement instruments. Findings demonstrated that variables measuring psychological dysfunction and homeless culture predicted alcohol addiction, while institutional disaffiliation and homeless culture predicted drug addiction. Findings affirm distinct patterns of estrangement related to alcohol compared to drug addiction. Understanding these features and the heterogeneity of this population has strong potential for assisting development of programs targeting substance use among this underserved population.

Social Control Correlates of Arrest Behavior among Homeless Youth in Five U.S. Cities

This study identified homelessness, substance use, employment, and mental health correlates of homeless youths’ arrest activity in 5 cities. Two hundred thirty-eight street youth from Los Angeles, Austin, Denver, New Orleans, and St. Louis were recruited using comparable sampling strategies. Ordinary least squares (OLS) regression results reveal that being arrested for criminal activity is associated with length of homelessness, history of juvenile detention and incarceration, receiving income from theft, substance abuse, and mental illness. Arrests are also associated with interactions between lack of formal employment income and receiving income from theft and between drug and alcohol abuse/dependency. Understanding the health and situational factors associated with homeless youths’ delinquent activity has implications for providing more comprehensive health, mental health, and substance abuse services.

VA’s Expansion of Supportive Housing: Successes and Challenges on the Path Toward Housing First

OBJECTIVES The U.S. Department of Veterans Affairs (VA) is transitioning to a Housing First approach to placement of veterans in permanent supportive housing through the use of rental vouchers, an ambitious organizational transformation. This qualitative study examined the experiences of eight VA facilities undertaking this endeavor in 2012. METHODS A multidisciplinary team interviewed facility leadership, midlevel managers, and frontline staff (N=95 individuals) at eight VA facilities representing four U.S. regions. The team used a semistructured interview protocol and the constant comparative method to explore how individuals throughout the organizations experienced and responded to the challenges of transitioning to a Housing First approach. RESULTS Frontline staff faced challenges in rapidly housing homeless veterans because of difficult rental markets, the need to coordinate with local public housing authorities, and a lack of available funds for move-in costs. Staff sought to balance their time spent on housing activities with intensive case management of highly vulnerable veterans. Finding low-demand sheltering options (that is, no expectations regarding sobriety or treatment participation, as in the Housing First model) for veterans waiting for housing presented a significant challenge to implementation of Housing First. Facility leadership supported Housing First implementation through resource allocation, performance monitoring, and reliance on midlevel managers to understand and meet the challenges of implementation. CONCLUSIONS The findings highlight the considerable practical challenges and innovative solutions arising from a large-scale effort to implement Housing First, with particular attention to the experiences of individuals at all levels within an organization.

The Andragogy of Evidence-Based Group Work: An Integrated Educational Model

Despite advances in group work education and in teaching about evidence-based practice (EBP), there has been little discussion about how to integrate EBP into existing educational models and how education about EBP can add to the effectiveness of group work practice. This article advances instruction in group work through articulating EBP within integrated instructional models. Each model consists of five elements—theory, evidence, group models, practice situation, and supervision—woven together in two ways. In one, EBP is conceptualized within an integrated instructional model that suggests that all elements are essential in education to advancing effective group work. In the second, a developmental instructional model articulates how these elements are delivered in teaching, which may be differentially applied based on the level of knowledge, skill, and experience of the learner. Through these models, the authors demonstrate how evidence-based group work principles integrate with skill development in the classroom, and how both can help to improve practice behaviors in group.

Modeling the mental health effects of victimization among homeless persons

Homeless persons are victims of violent and non-violent crime at higher rates than housed populations. While studies have suggested that victimization can induce or exacerbate mental health problems, there is very little known about factors that may buffer the effects of victimization. This cross-sectional study examined the influence of victimization on depressive symptoms in over 9600 homeless and mentally ill adults participating in the Access to Community Care and Effective Services and Supports study (ACCESS) conducted in multiple cities across the USA relationships between victimization, depressive symptoms, and perceived safety were tested within a structural equation modeling framework using data collected at the baseline interview. The overall model exhibited a good fit with the data. Non-physical victimization was associated with higher levels of depressive symptoms, and physical victimization was associated with lower levels of perceived safety. As hypothesized, perceived safety was a significant partial mediator of depressive symptoms. These results underscore the complexity of the relationships between victimization and depression in homeless adults and the importance of addressing different types of victimization in homeless and mentally ill adults.