Model

Critical Time Intervention (CTI) is an empirically supported, time-limited case management model designed to prevent homelessness and other adverse outcomes in people with mental illness following discharge from hospitals, shelters, prisons and other institutions. This transitional period is one in which people often have difficulty re-establishing themselves in satisfactory living arrangements with access to needed supports. We believe that focused, time-limited assistance during this critical period can have enduring positive impacts. Although most of our work to date has been with adults with mental illness following institutional discharge, we believe that this approach may also be relevant to other populations at a variety of critical periods.

CTI was originally developed and tested by researchers and clinicians at Columbia University and New York State Psychiatric Institute with significant support from the National Institute of Mental Health and the New York State Office of Mental Health. The model is currently being broadly applied and tested in the US and abroad.

The principal goal of CTI is to prevent recurrent homelessness and other adverse outcomes during the period following placement into the community from shelters, hospitals, and other institutions. It does this in two main ways: by strengthening the individual’s long-term ties to services, family, and friends; and by providing emotional and practical support during the critical time of transition. An important aspect of CTI is that post-discharge services are delivered by workers who have established relationships with patients during their institutional stay. Typically these workers are bachelor’s or master’s level individuals operating under the supervision of an experienced clinically trained professional. The CTI workers must be flexible and creative as well as comfortable working primarily in the community. At the same time, they must be committed to following a rather focused model of care. Once the worker has established a relationship with the client and begun to organize his or her support plan, the post-discharge phases of the intervention are delivered as follows: (1) Transition to the community, (2) Try-out, and (3) Transfer of care.

Transition to the community The first phase focuses on providing intensive support and assessing the resources that exist for the transition of care to community providers. Ideally, the CTI worker has already begun to engage the client in a working relationship before he or she moves into housing in the community. This can be accomplished formally or informally, depending on the institutional setting and the role of the worker within the institutional system, and may consist of multiple meetings or just one or two contacts. This is important because the worker will build on this relationship to effectively support the client following discharge from the institution. During the first few weeks following this move, the CTI worker maintains a high level of contact with the client, both through regular telephone calls and home visits. Interim psychiatric treatment (including providing access to medication as needed) can be arranged by the team until adequate community arrangements are in place. This assures that treatment will not be interrupted during this early critical period of transition. Clients are accompanied to appointments with selected community providers, such as mental health and medical clinics. The CTI worker “introduces” the client to his or her new providers in order to facilitate the development of a durable tie and encourages them to negotiate compromises when problems arise.

The CTI worker also meets with key figures in the client’s residence. These figures are most often the primary caretaker in a family home or staff in a supervised residence, but in some cases may include a single-room occupancy hotel manager or an involved neighbor. The CTI worker offers support to these persons while making it clear that he or she is prepared, when necessary, to mediate a compromise between them and the client. They discuss potential housing crises and try to identify ways to avoid them or possible coping strategies and resources, should a crisis occur. The CTI worker also works with the client and primary caretaker on skills for crisis resolution, such as how to listen to each other, and how to speak to each other without going on the attack. Tensions tend to arise quickly as caretaker or staff and client attempt to adjust to one another. As with the community service providers, a compromise developed during this early phase of adjustment may prevent later loss of housing. This work sometimes takes the form of family psychoeducation in which the CTI worker may educate a family member about the client’s mental illness; this frequently contributes to enhanced family support as relatives come to understand that problem behaviors have causes other than “bad behavior” or substance abuse. However, compromise is not helpful or appropriate in all situations. For instance, when the primary caretaker is a mother with a history of injection drug use who relapses after the client moves back in with her, the best plan of action may be to assist the client in locating alternative accommodations.

During these initial intensive contacts, the worker is also gathering data needed for treatment planning in the transition period. He or she works together with clients and service providers to detail proposed arrangements to ensure medication adherence, money management, or control of substance abuse. These arrangements are then tested in vivo and modified if necessary during the transition period. The CTI worker generally makes detailed arrangements in only the handful of areas that are seen as most critical for the community survival of that individual (i.e., medication adherence); it is important not to be overly ambitious. There is also a strong emphasis on assessing the feasibility of the support systems that are established because they are intended to persist well after the CTI worker has terminated services. During this initial period, the worker must also recognize when clients’ lack of participation in some programs may indicate that the services being offered are incompatible with their needs. For example, a young man with a substance abuse problem explains that he does not regularly attend the treatment group meetings to which he has been referred because the issues discussed by the other, much older, group members do not address his concerns. In this case, rather than attempting to help the client to adjust to the group, the CTI worker may help him identify another group composed of younger people.

Try-out The second phase of CTI is devoted to testing and adjusting the systems of support that were developed in the first phase. By now, community providers will have assumed primary responsibility for the provision of support and services, and the CTI worker can focus on assessing the degree to which this support system is functioning as planned. During Phase Two, the worker encourages the client and members of his or her support system to handle problems on their own. The worker meets with the client less frequently, but maintains regular contact in order to observe how the plan is working and be ready to intervene when a crisis arises. In many cases, further modification of the support system is required. Such “system adjustment” may be accomplished via a case conference or less formal meetings between the client and those involved in the support system. The CTI worker acts as a primary resource for all parties and assists them in devising a framework for resolving potential conflicts. For some clients, this period requires a renegotiation of treatment plans and a more active role for the CTI worker in facilitating the implementation of these plans. The in vivo monitoring role assumed by the worker may also be helpful in identifying specific clinical treatment issues (such as medication non-adherence) that may elude even the most caring office-bound clinician.

Transfer of care The final phase of CTI focuses on completing the transfer of care to the community resources that will provide long-term support to the client. One of the strengths of the CTI model that differentiates it from the services typically available to clients during transitional periods is that the transfer-of-care process is not abrupt; instead, it takes place over nine months. Throughout the intervention, the CTI worker has gradually reduced his or her role in delivering services to the client in the community. By the time Phase Three begins, the worker has gradually prepared the client and linkages for his or her new role as consultant. The main function in this phase is to ensure that the most significant members of the support system meet together and, along with the client, reach a consensus about the components of the ongoing system of care. Ideally, this occurs at least one month before the end of the nine-month period of the intervention. This gradual process ensures that the termination of CTI is not perceived by the client and the members of his or her support system as a sudden, potentially traumatic, loss.