This essay represents a meta-analysis of the available literature that is relevant to the Critical Time Intervention (CTI) model. The article addresses core components of the CTI model including obstacles that frequently emerge in the delivery of support services to the mentally ill homeless populations. Empirically based research is presented in effort to demonstrate efficacy with a variety of populations including prospective clients who have recently discharged from hospitals and long term treatment facilities (including the VA). Finally, the article addresses some of the obstacles of working with “elusive populations.” This discussion is set in an accountability context for providers to continue to be able to demonstrate efficacy in a grant driven environment. Ethnographic approaches are identified and clarified to such end that the individual practitioner can be more effective working with this challenging population.
Critical Time Intervention (CTI)
The prevention of homelessness among the mentally ill is a vital issue for public health. “In the United States, men and women with chronic mental illnesses such as schizophrenia have a 25% to 50% risk of becoming homeless, which is about 10 to 20 times the risk of homelessness for the general population.” (Susser et al., 1997, p. 256) The Critical Time Intervention (CTI) model is a comparatively new, empirically supported, time-limited case management model designed to support individuals who are at high risk for homelessness due to being recently discharged from hospitals, shelters, prisons, and other institutions. These individuals are prone to all the hardships of a “make-or-break” trapeze leap of establishing housing stability – as evidenced by the statistics above, it is evident that too many find their way into the ranks of the homeless. CTI is an attempt to reduce homelessness and improve outcomes for this high risk population.
The homeless population is, traditionally, one of the most difficult-to-treat groups. Not only is the population a hotbed for mental illness, research suggests that more than half of the homeless population suffer from comorbid substance misuse in addition to mental illness. In addition, the homeless population doesn’t typically comply with the usual “help-seeking behavior” and, as a result, are often seen as beyond the reach of traditional helping methodology. (Thornicroft, 1997, p. 158) There is little incentive for more traditional helping organizations to aggressively pursue individuals for treatment because, apparently, the mentally ill homeless population is seen as a systemic casualty that is “so far gone that resources are better devoted to potential clientele that really want help.” CTI attempts to break this cycle of systemic neglect by acknowledging and modifying traditional support delivery systems to fit the specific needs of the homeless population.
CTI is a nine-month, three-stage intervention that strategically develops individualized linkages in the community and seeks to enhance engagement with treatment and community supports vis-à-vis the facilitation problem-solving skills, motivational interviewing, and advocacy with community agencies. (Draine & Herman, 2007, p. 1577) CTI provides a “bridge between institutional and community care” that is too frequently unavailable in the current environment. (Susser et al., 1997) The model as it applied to prisoners is delineated below:
CTI represents a significant departure from the “usual care” status quo. Although the type and quality of “usual care” will vary from market to market, one study provided significant detail of what “usual care” constitutes. (Susser et al., 1997, p. 257)
A recent randomized trial that examined 150 previously homeless men and women suggests that CTI produced statistically significant reductions in the occurrence of rehospitalization after hospital discharge. (Tomita & Herman, 2012) Despite the fact that the CTI model is a relatively brief intervention, CTI produced real results with “a fivefold reduction in homelessness risk.” As evidenced in Figure 1 below, identifying and leveraging needed supports during the nine month transitional period clearly has the potential to produce significant gains in client outcomes over the long term. (Herman, Conover, Gorroochurn, Hinterland, & Hoepner, 2011, p. 718)
CTI interventions intended to strengthen the individual client’s long-term connections to community services have also demonstrated efficacy for homeless veterans with mental illness who were leaving Department of Veterans Affairs (VA) inpatient care. Veterans demonstrated better work history, better medication compliance, fewer days in institutional settings, and significant reductions in Addiction Severity Index (ASI) alcohol use and psychiatric problem scores. The study concluded that “a sustained training program can be used to implement CTI in systems that have little past experience with this approach and can yield improved housing and mental health outcomes.” (Kasprow & Rosenheck, 2007)
Although the original conceptualization of CTI aims to provide significant emotional and practical support throughout a nine month critical intervention window, even more time limited randomized trials have been conducted with significant success. “Brief three-month critical time intervention” (B-CTI) demonstrated statistically significant increases in post discharge continuity of care for persons with serious mental illness. This was accompanied by significantly fewer days between their hospital discharge and their first outpatient service, and increased likelihood to have more total mental health and substance abuse visits within 30 and 180 days of discharge, and a greater number of two-month blocks with two or more outpatient visits over 180 days. “Participants in the B-CTI group reported receiving more help in making and keeping medical and mental health appointments, making family contact and community connections, and receiving information on prescribed medications.” (Dixon, Goldberg, Iannone, Lucksted, & Brown, 2009, p. 451) This may suggest that even among CTI attrition casualties there may be some residual benefit in the form of better outcomes.
Although the CTI model certainly does not have a monopoly on the development of supports like family and friends, CTI is unique in the regard that CTI team interventions expend considerable time and resources in the acquisition and maintenance of “natural” social supports. Some portion of the therapeutic intervention will inevitably be delivered in the outpatient office setting, but a significant portion of the direct contact is conducted in the community. “CTI is not intended to become a permanent support system; rather it ensures support for none months while the person gets established in the community.” (Draine & Herman, 2007, p. 1578)
The phases of the CTI model are delineated into three trimesters as delineated below: (Critical Time Intervention [CTI], 2012)
(Phase 1) Transition to the Community
Like most therapeutic interventions, assessment plays a key role in the first phase of treatment. The specific needs of the client are assessed and subsequently matched to the appropriate community based treatment providers. Ideally a relationship is established and rapport is built even before institutional discharge. The importance of this “soft handoff” cannot be understated. This can be accomplished with a series of meetings and/or phone contact with the institutional treatment team and/or the client themselves. High levels of ongoing contact are the bellwether of this phase of treatment, both through regular telephone calls and home visits. Under most circumstances pharmacological treatment has already been initiated and medication regiments have been stabilized during the institutional stay – so a key component of the early intervention is establishing access to medication as needed. Clients are accompanied to appointments with selected community providers to assure a continuity of care. Early treatment objectives include “introducing the client to their new providers in effort to establish and maintain a durable working relationship with community service providers in all appropriate disciplines.
As mentioned previously, the establishing working relationships with friends and family represent an ongoing focus of treatment. Although these figures vary from case to case, potential targets include primary caregivers, supervisory staff (in the case of a managed care residence), hotel managers, landlords, or even involved neighbors. Where the CTI model departs from more traditional models is that support is offered directly to these stake holders. Conflict resolution services and express delivery of solution focused coping strategies to avoid and avert potential obstacles to continued client stability are offered. Typical strategies that can aid in communication facilitation might include direct conflict mediation and/or ongoing training (for both the client and the vested caretakers) on listening, effective conflict resolution, etc. The CTI professional should anticipate obstacles specific to a given diagnosis.
Potential treatment goals include medication adherence, money management, and control of substance abuse. Interventions are tested in vivo and modified (as necessary) to ensure long term feasibility of critical support services in anticipation of continuance of said support services long after the client has terminated services with the CTI program. Non-compliance could (and perhaps should) be interpreted as an indication that services offered and incompatible with client needs. (CTI, 2012)
(Phase 2) 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 treatment team can focus on assessing the degree to which the support system and services are functioning as intended. Phase two is intended to be a period of transition in which clients and supports are encouraged to be proactive and handle issues on their own. Although the CTI team remains “at the ready” to provide support in the event of a crisis, the frequency of CTI support team visits are significantly reduced. Regular contact is often confined to less formal meetings and is frequently targeted at “system adjustment” in effort to assure that all parties have the necessary resources to address specific clinical treatment issues. (CTI, 2012)
(Phase 3) Transfer of Care
As the namesake of phase three implies, the final phase of CTI is focused on completing the transfer of care to the resources that were identified in phase one, and adjusted in phase two. One of the significant strengths of the CTI model is that the transfer-of-care is not abrupt. This phase is marked by further reduction in the service delivery on the part of the CTI team. Termination issues are addressed to such end that the client does not perceive the loss of the CTI team supports as sudden, potentially traumatic, loss. (CTI, 2012)
Accountability and the “Insider’s Perspective”: How do we measure our effectiveness with “elusive populations?”
The continued availability of grant funded community support programs like CTI is contingent on CTI providers being accountable for results. “Most studies that have attempted to test preventative interventions have failed to achieve conclusive results, partly because of the difficulty of follow-up in this population.” (Susser et al., 1997, p. 256) Because traditional follow-up techniques (including scheduled appointments, telephone and mail notification, home visitation) are often insufficient methods with elusive populations, some alternative method for follow-up must be devised if any longitudinal assessment of CTI effectiveness is to be achieved. These populations often have a different frame of reference and author a different reality – they are highly mobile, transient, and otherwise difficult to reach. (Conover et al., 1997, p. 92) Research suggests that the homeless, the mentally ill, substance abusers, and illegal immigrants are better accounted for by employing a more ethnographic approach.
What does this “ethnographic approach” entail? First and foremost, collecting reliable data depends on the development and maintenance of a working relationship based on mututal trust, caring, and respect. It is imperative that the client understands that the CTI worker is “on their team.” Secondly, it is paramount that CTI workers learn as much as is possible about the clients’ “ecology” including (but not limited to) characteristics of their physical environment, the services and institutions they have employed in the past, and their network of social contacts (including friends, family, and other social services/networks). The importance of empathy cannot be understated since these individuals are (at least initially) depending on the consistency and comfort provided by the CTI team. (Conover et al., 1997, p. 95)
“Street smarts” is a prerequisite for success as a CTI team member. Because the CTI program requires CTI workers to track participants in some potentially dubious neighborhoods, it should go without saying that the CTI worker should be able to navigate those treacherous waters. Because the police and other officials are often viewed as objects of fear (rather than sources of help or protection), it is important that the CTI worker present themselves as professional but not authoritative. (Conover et al., 1997, p. 96) When attempting to track and follow up with transient clients, CTI workers should expect to be both flexible and creative in efforts to locate participants. Every successive interview should deepen the CTI interviewers understanding of the participant – thus making the client easier to locate when he or she turns up missing. (Conover et al., 1997, p. 97-98) Finally, interviewers should take whatever steps are necessary to ensure that participants aren’t inadvertently treated as non-persons. Structured interviews administered formally convey a sense of unequal power that may lead many homeless individuals to believe that interviewers are explicitly scrutinizing or judging their behavior. Interviews should be as conversational and informal as is possible while still attending to the collection of needed information. Researchers found this was particularly helpful when discussing sexual behaviors and drug or alcohol use. (Conover et al., 1997, p. 100-101) Interviewers should be wary of clients that are prone to “social acceptability” bias – essentially giving answers the interviewee believes will please, impress, or somehow aid the interviewer. In any case, any standardized measure or questionnaire should represent a task shared, but it should never represent the defining relationship between the interviewer and the interviewee. (Conover et al., 1997, p. 101)
Conover, S., Berkman, A., Gheith, A., Jahiel, R., Stanley, D., Geller, P. A.,…Susser, E. (1997). Methods for successful follow-up of elusive urban populations: an ethnographic approach with homeless men. Bulletin of the New York Academy of Medicine, 74(1), 90-108. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2359247/pdf/bullnyacadmed01029-0096.pdf
Critical Time Intervention. (2012). Model. Retrieved November 21, 2012, from http://www.criticaltime.org/model-detail/
Dixon, L., Goldberg, R., Iannone, V., Lucksted, A., & Brown, C. (2009, Apr). Use of a critical time intervention to promote continuity of care after psychiatric inpatient hospitalization. Psychiatric Services, 60(4), 451-8. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com/docview/213119561?accountid=28125
Draine, J., & Herman, D. B. (2007, Dec). Critical time intervention for reentry from prison for persons with mental illness. Psychiatric Services, 58(12), 1577-81. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com/docview/213094132?accountid=28125
Herman, D. B., Conover, S., Gorroochurn, P., Hinterland, K., & Hoepner, L. (2011, Jul). Randomized trial of critical time intervention to prevent homelessness after hospital discharge. Psychiatric Services, 62(7), 713-9. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com/docview/1095834626?accountid=28125
Kasprow, W. J., & Rosenheck, R. A. (2007, Jul). Outcomes of critical time intervention case management of homeless veterans after psychiatric hospitalization. Psychiatric Services, 58(7), 929-35. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com/docview/213078736?accountid=28125
Susser, E., Valencia, E., Conover, S., Felix, A., Tsai, W., & Wyatt, R. J. (1997, Feb). Preventing recurrent homelessness among mentally ill men: a critical time intervention after discharge from a shelter. American Journal of Public Health, 87(2), 256-262. http://dx.doi.org/10.2105/AJPH.87.2.256
Thornicroft, G. (1997, Feb). Annotation: the importance of transitional care in reducing homelessness. American Journal of Public Health, 87(2), 158-9. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1380785/pdf/amjph00501-0016.pdf
Tomita, A., & Herman, D. B. (2012, Sep 1). The impact of critical time intervention in reducing psychiatric rehospitalization after hospital discharge. Psychiatric Serv, 63(9), 935-937. http://dx.doi.org/10.1176/appi.ps.201100468