Implications of the study

4.1 Improvement and further development of Houvast

This study does not allow to draw conclusions on the effectiveness of the Houvast intervention. It was recommended that future research is needed on the effectiveness of Houvast once sufficient model fidelity of the intervention in the trained shelter facilities is established. Houvast is based on the strengths-based approach (Rapp & Goscha, 2011) and different studies have proven the effectiveness of this approach. Studies showed consistently positive outcomes on number of hospitalizations, quality of life or social functioning and social support (Barry et al., 2003; Björkman et al., 2002; Kisthardt, 1994; Macias et al., 1997; Modcrin et al., 1988; Stanard, 1999). However, one has to bear in mind that the strengths-based approach was developed in the United States and these studies were conducted in the United States as well. Because of differences in policies, welfare state, health care insurance and care system, there may be differences regarding the execution of the Houvast intervention. Nevertheless, many participating shelter facilities have responded enthusiastically to Houvast (e.g., experienced a positive team or group atmosphere) and decided to continue with Houvast and to provide training to professionals working in other shelter facilities after the study was finished. Also, shelter facilities and organizations that for whatever reason decided not participate in the current study showed an interest in the Houvast intervention. Based on the results of this study and the experiences reported by professionals, team leaders and managers during the execution of the study, some suggestions for further development of Houvast can be made. These are described in the next paragraphs.

Selecting your own mentor

The results in chapter 6 showed that homeless young adults’ perspective of the working alliance is important for the improvement of self-determination and resilience. This knowledge can be used to think about ways or tools to create an optimal working alliance for homeless young adults in which they feel safe enough to express their needs and feelings. From the onset of receiving ambulatory or residential care, a young adult is generally assigned to a professional (mentor). This mentor provides overall guidance, emotional and practical support in multiple life domains (e.g., finances, housing, employment, health) during the trajectory towards recovery. The mentor, in particular, is designated to support several homeless young adults and works with them to attain the goals they had set for themselves. Although it takes time to develop a trustful relationship, it is possible that sometimes a meaningful relationships cannot be established. For homeless young adults, this can be another negative experience leading to dropout (De Winter & Noom, 2003). To prevent this undesirable situation, it might be helpful to give homeless young adults a choice in

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selecting their own personal mentor when entering the shelter facility. Our results support this suggestion as it was found that homeless young adults showed more improvement on self-determination and marginally on resilience when they experienced a stronger working alliance compared to other young adults of the same professional (chapter 6).

Motivational interviewing

Professionals working with homeless young adults ideally try to build a safe and secure working alliance by creating an open learning environment in which they seek a dialogue with homeless young adults, give them feedback, and support them in choosing and attaining their own personal goals. In order to reach goals, it is important to set goals that have intrinsic value to a homeless young adult. Goals are rarely achieved when they do not meet this criterion (Ryan & Deci, 2000b; Wolf, 2012b). The principles of a technique called ‘motivational interviewing’ can be used in order to fulfill this criterion.

Motivational interviewing is grounded in the self-determination theory and appears to be an appropriate technique to help create the conditions for good quality care and positive outcomes (Markland et al., 2005; Miller, 1983). Motivational interviewing is designed to strengthen an individual’s intrinsic motivation for and movement toward a specific goal by eliciting and exploring the person’s own arguments for change. Among homeless adolescents in the United States, it was found that illicit drug use decreased among those who received motivational interviewing. However, the effects of brief motivational interviewing were not consistent at long-term highlighting the importance of long-term care for this group (Baer, Peterson, & Wells, 2004; Peterson, Baer, Wells, Ginzler, & Garrett, 2006).

The studies described in this dissertation emphasize the importance of motivational interviewing. In chapter 2, it was described that in the Houvast intervention, homeless young adults are in the lead of their recovery process, that the working relationship is primary and essential and that recovery starts with establishing a trusting working alliance. In chapter 5, it was concluded that it is important for intervention programs for homeless young adults to focus on the enhancement of self-determination, especially competence, to improve their quality of life. Finally, in chapter 6, it was concluded that homeless young adults’ perspective of the working alliance is very important for positive outcomes. Motivational interviewing fits well with these findings and fits perfectly with homeless young adults’ wish be taken seriously and prefer to receive care from professionals who are committed, honest, authentic and flexible (Planije et al., 2003; Wolf, 2012b).

Motivational interviewing is an integral part of the Houvast intervention and should be part of facilities who deliver care-as-usual. In the future, professionals should be encouraged and supported to use the principles of motivational interviewing

more explicitly. There are four general principles: the expression of empathy, the development of discrepancy, rolling with resistance, and support for self-efficacy (Miller & Rollnick, 2002). When applying this to homeless young adults, this means the following: 1) the professional needs to show empathy as a crucial element for a successful exploration of change to take place; 2) the professional needs to explore the pros and cons of homeless young adults’ current behavior in order to make them aware of the discrepancy between their current behavior and their goals; 3) the professional needs to accept ambivalence and resistance of the homeless young adults and should not try to engage in conflict or to counter homeless young adult’s arguments against change, 4) the professionals need to support homeless young adults’ self-efficacy as it is believed that change will not occur unless the young adult believes in his own capabilities.

4.2 Policy implications

In January 2015 started a major decentralization of tasks and responsibilities regarding welfare, youth care and participation from central government to local municipalities in the Netherlands. The general aim of this decentralization is to organize and provide services in closer proximity with citizens, and to work more efficiently, more coherently and more cost-effectively. Nowadays, municipalities have the obligation to help citizens to find work and stay employed, and are integrally responsible for youth care and for the stimulation of self-reliance of vulnerable citizens, such as homeless young adults (Schalk, Reijnders, Vielvoye, Kouijzer, & de Jong, 2014).

The decentralization gives municipalities much greater responsibility for the care of homeless young adults. For example, they are responsible for organizing supported living accommodations and providing early intervention via local district-teams. The policy is to focus on vulnerable citizens in general instead of specific groups of vulnerable citizens, such as homeless young adults. As a result, in the future there might be no funding available any more for services specifically targeted at homeless young adults. Because of this policy change and the cost reduction that goes hand in hand with the decentralization, a radical change is to be expected in the organization of the care for homeless young adults. Time will tell if homeless young adults are better off with decentralized policies by local municipalities. Perhaps this change will make it possible to solve a substantial problem in service delivery when youth reach the age of 18. When they turn 18 years old, young adults are often allocated to other care providers and need to exit institutional youth care settings where they were taken into custody. Also, they are free to choose whether they want to receive care or not and many of them decide to leave care at this age. As a result of this, the transition from youth care to adults care often resulted in homelessness among young adults (VWS, 2011b). On paper, the decentralization offers good opportunities

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to address this transition problem (Kinderombudsman, 2015) because municipalities are nowadays responsible for both youth care and the care of homeless young adults. For example, they can diminish the strong distinction in service provision for both groups.

The principles, and theoretical and conceptual models on which Houvast is based seem to fit perfectly with one of the goals of the decentralisations, namely to make more use of personal strengths and of help and opportunities in the environment. Also, the trend towards a society in which people receive more ambulatory care seems to fit perfectly with the principles of Houvast. Namely, focusing on building, maintaining and emphasizing the young adults’ social network by meeting them in their own environment and trying to involve them in the community. Altogether, the Houvast intervention or other interventions which focus on these principles might be of interest for municipalities.