Critical Time Intervention – A model to enable transition to sustainable living

Introduction

Critical Time Intervention (CTI) involves a phased and time-limited (9 months) approach to community-based rehabilitation of a vulnerable client towards independent and sustainable living. It is specific to the period of transition of the person moving from a shelter or hospital ward to living in the community and its implementation involves a planned and progressively decreasing intensity of involvement of the service provider with the client. The period of transition is a time of heightened vulnerability, when a person requires added inputs to develop and repair ties to the community and to service providers of relevant support services . Unfortunately, a person confronts a fragmented, chaotic and sometimes hostile landscape in this period. In this context, CTI provides the crucial bridging help for the individual in need of community integration and continuity of care.

CTI resembles long-term assertive community treatment (ACT) and intensive case management (ICM) in its aim of integrating clients in the community by encouraging and strengthening their skills of independent living skills and building and accessing support networks. All three approaches involve community-based activities of outreach, engagement and sometimes mediation of relationships between clients and support services. The crucial distinction is that CTI is geared to the needs and challenges of the period of transition from shelter into community. The CTI focus is on mobilizing and strengthening support networks and enabling the client to stay connected to those supports as well as to seek out new supports after the CTI intervention comes to a planned halt. CTI is not an intervention of long-term case management (Herman 2013).

In this post, I examine whether the 9-month periodization of CTI might make it a suitable intervention (or at least a compromise in lieu of more stable and long term rehabilitative programs) for a service landscape that is marked by short-term funding and short-duration service models, which obstruct long-term connections and follow-up to improve and stabilize outcomes.

History of CTI

CTI originally evolved to support individuals in homeless shelters as they transitioned into community living. It has been applied to veterans, people with mental health challenges, people exiting prison, homeless shelters and refuges for survivors of abuse. The need for CTI as a support approach emerged because it was observed that newly rehomed persons often again became homeless in the period after transition from shelter into community living. Often, persons had substance dependency, mental and physical challenges, and suffered from the effects of mental and physical trauma. These were barriers to independent living and to the retention of income and housing. In the service landscapes of neoliberal economies, clients are typically expected to be independent and proactive in navigating and accessing service systems. The challenge is that persons coping with trauma and illness often find it a harrowing experience to access services that are often fragmented, confusing and very often plain inaccessible. The transition period can also be a difficult time in the relationship between the client and his or her family and social network who may not be aware of how best to provide needed support.

The introduction and testing of CTI involved randomized controlled trials (RCTs) of the approach with persons with challenges of mental health and homelessness (Herman 2013). The RCTs described in Susser et al 1997 and Herman et al 2011 found that CTI reduced the risk of recurrent homelessness and rehospitalization, with the protective effects lasting for around 9 months after the end of the intervention.

CTI RCTS

The phases of CTI  (Adapted from https://www.criticaltime.org/cti-model/

Pre-CTI (Month 0-1)

The CTI worker establishes rapport with client.

Transition (Months 1-3)

The purpose of this phase is the provision of specialized support and the implementation of a transition plan. The CTI worker’s activities are as follows:

  • Makes home visits (Frequency is need-based but decreasing over the phases. Recommendations are weekly during Phase 1, bi-weekly during Phase 2, and monthly during Phase 3.) During Phase 1, at least four meetings should take place in the community, after worker has established clients’ preferences on timing and location of visits).
  • Engages in collaborative assessments
  • Meets with caregivers
  • Accompanies clients to community providers and makes introductions. Linkages should be (i) based on needs assessment and (ii) appropriate to client needs, strengths, and aims.

Try-Out (Months 4-7)

The purpose of this phase is to monitor, facilitate, troubleshoot and strengthen support network and client’s skills. The CTI worker’s activities are as follows:

  • Observes operation of support network
  • Helps to modify network as necessary
  • Substitutes for caregivers when necessary
  • Gives support and advice to client and caregivers
  • Mediates conflicts between client and caregivers

Transfer of care (Months 8-9)

The purpose of this phase is to complete the closure of CTI services with support network safely in place. The CTI worker’s activities are as follows:

  • Reaffirms roles of support network members
  • Provides and initiates implementation of plan for long-term goals (e.g. employment, education, family reunification).
  • Holds meeting with client and supports  to symbolize transfer of care
  • Meet with client for last time to review progress made
  • Steps back to ensure that supports can function independently

Download the table of CTI phases as a PDF or view and save the image below.

CTI PHASESGiven that CTI recipients frequently have severe problems that need support for longer than 9 months, it is valid to ask about the possibility of extending CTI beyond the 9-month timepoint. The guidance available is clear that to retain fidelity to the model, the phases should not be extended. The purpose of the intervention is to link the client to supports for long-term needs. CTI itself is not meant to be long term.

Under which circumstances may CTI phases be extended?

The CTI phases should not be extended. A grace period of two weeks is permitted to terminate the intervention after the originally planned closing date. In the event that a client is continuously out of contact for more 25 percent of the intervention’s total duration (which may vary among programs), the CTI worker may re-start the intervention upon the client’s return. Otherwise, the CTI worker works with the client along the originally planned timeline.

Should the CTI period be extended if a client has not met their long-term goals (e.g. finding a job, enrolling in school, maintaining medication compliance) within the CTI timeframe?

One should not expect clients to meet their long-term goals within the short timeframe of CTI. Instead, the goals of the CTI phases are related to successful linking of clients to supports who will eventually take over helping clients meet their long-term goals.

Should a CTI worker extend Phase 3 if the client has not been linked to sufficient supports/services?      

Although each case presents its own unique challenges, it is generally recommended that under such circumstances the client still BE discharged at the originally planned closing date of the intervention. However, an extension of the CTI phases may be appropriate if specific services/supports are likely to become available in the near future and the client is willing to be linked to such services/supports.

If a client contacts a CTI worker post-termination requesting assistance during a crisis, what should the worker do?

A CTI worker should not be the ongoing contact for crisis intervention. The worker should remind the former client that CTI is over, offer some limited advice and re-direct the client to the supports and sources of help to which he or she was hopefully connected during the intervention. Do not re-open the case unless there is another major life event where CTI might help with the transition.

https://www.criticaltime.org/cti-model/cti-implementation-faqs/

CTI’s relevance to women who are rebuilding lives after escaping a violent home and leaving a shelter

The transition to independent living after time in an abusive relationship and then time in shelter is fraught with challenges – with struggles around housing, income, childcare, and “post-separation” violence, and the effort to create new social networks. In this time of transition, support measures are needed to strengthen practical skills, create psychosocial resources, and supportive connections to prevent a return to violence because of the aftereffects of abuse and trauma coupled to lack of social support and connections. Sufferers of violence may have mental health issues that need sustained and judicious attention.  The lingering trauma of years of violence brings depression, anxiety, withdrawal, learned helplessness, hopelessness, and profound fear of not being believed, understood or helped.

The irony is that even with these many barriers, survivors of violence are expected to be proactive in obtaining supports. The fact is that survivors need help to transition through the steps of anti-violence service, to find and retain supports, and to start and hold on to some form of sustainable independent living. See Lako et al 2013 for a description of CTI’s relevance to women leaving shelter and for the protocol of two randomized control trials investigating whether ‘CTI is more effective than care-as-usual for abused women and homeless people making the transition from shelter facilities to supported or independent housing’.

In the context of Edmonton’s patchwork and financially strapped anti-violence service landscape, in a system wherein traumatized help-seekers are shunted from one agency to the next, there is a need for interventions like CTI that enable some measure of continuity of client-provider relationship, sustained connections and referrals within a brief time frame, and follow-up on client progress to a normal and safe life.

So I think transition is huge. I did a lot of volunteering in women shelters out in Calgary. One thing that I really liked in the shelter that I had spent some time in in volunteering and doing some shadowing is they had transition plans. Not only did they keep women safe when they first came in but a lot of these women are so isolated from the world. So how do you drive, like driver’s license or how do you grocery shop by yourself? How do you pay the bills? You know, just all of those what I consider daily activities that I do daily or even how to write a resume or how to apply for a job or how to talk to someone. Those are skills that a lot of women who are isolated or come from these kind of violent homes don’t have those skills. One thing that I really appreciated is in the shelter that I was volunteering at, they had these services and people with time and patience to teach these women and young girls these skills. So not only are we trying to keep you safe but we don’t want to isolate you here either. We want to help you grow and be independent and kind of be that strong woman and not just shelter you again. [Link]

During conversations with anti-violence service providers, a frequent theme has been that help-seekers feel anxious about transitions from one link in the service chain to the next and often report concern (and anger) about being abandoned by a service provider with whom they had built up a measure of rapport. This sense of abandonment and sometimes even anger at feeling let go and let down by a trusted figure can persist before, during and after time in a shelter. CTI can ameliorate this by creating a network of supports for the survivor.

I told my client that there’s a space in the shelter for her. And then she says, “Are you going to send me over there? Don’t contact me anymore.” I say, “No. Maybe I’m not speaking clearly. I say we have ongoing support and we find you a place to stay there for the safety of your child and I will go over and visit you and then we’ll work with the worker over there. It’s not like we throw you under the bus or just to other people.” They’re really afraid of being abandoned. [Link]

Providers informed us that the task of rehabilitation and living independently is vastly complicated by the mental health issues of women who have survived abuse. For example, it may be difficult to adjust to ‘normal’ life, to loneliness, to seek and/or hold on to housing and employment. One interviewee described a poignant situation (this conversation was not audio-recorded and thus there is no transcript). A minority client with rent-assisted housing felt unable to let the housing program staff inspect her unit, which is a mandatory part of the rent assistance program. The program staff were unable to connect with the client or with an agency that could have communicated with her to solve the problem of access. As a result, the client’s rent-assisted housing was in jeopardy. The long-lasting effects of abuse sometimes surface after a delay. This is one of the many reasons case workers needs to sustain connection and engagement with survivors to ensure that their mental health has a chance of improving and that trauma does not overwhelm them in the world they navigate after abuse and after shelter. Psychoeducational counselling, along with some career development plans and exposure to social and educational possibilities, is needed to create options that would create the strength necessary for independent living. The CTI worker can help prevent revictimization through financial distress, homelessness, learned helplessness, loneliness, the long-term effects of trauma, and psychosocial pressures to return to the ‘father of the children.’

So a lot of this is educating them about the social kind of network that is there and then emotional support which is the big piece. Having somebody just to listen to after they have left.  They have kind of had a very intense kind of three weeks at the shelter where they were just surrounded by our staff and you know 24 X 7 they have a social worker there to talk to and they go for that to being alone and they are trying to kind of pick up the pieces from there. You know it is a hard transition from a shelter which is so busy and you know loud and going from that into living on their own so we provide them some services so that they can make that transition. We are educating them about how to continue to be safe. So we do a lot of work around safety planning because after they have left the security of the shelter they are suddenly vulnerable again to their perpetrator and where things are at you know legal case for instance or custody and arranging transition time and safe drop-offs and things like that. So we do support her through some of that. This will also be for the first few months when she is encountering that so we continue to assess the risk that she is in throughout that period. [Link]

Factors in CTI Implementation

The implementation of CTI is predicated on the compatibility of the model with the mandate of the implementing agency, the level of training of the staff, and the staff’s existing case load (which should allow for the agency to include a small number of cases for CTI). See this 2015 study by De Vet and colleagues examining factors that impact fidelity in CTI implementation for homeless people and abused women leaving shelters in the Netherlands. The implementation of CTI specifically requires no early discharge and no post-termination resumption of CTI. This implies challenges of delivery (a) when there is a surge in regular caseload during the provision of CTI to some clients (b) when the CTI recipient requires new or continued help and reconnection.

In Edmonton, shelter outreach mandates may be in conflict with CTI, which would be the barrier to using CTI, apart from the limited knowledge of the intervention protocol. For example, with those who have lived in a second-stage shelter, an outreach worker would be able to work with the participant for up to 3 months after move-out, which is shorter than the 9 month CTI timeline… For outreach participants that have not lived in shelter, service is not limited to a time, but continues until the service is no longer needed by the participant – based on experience, this may be anywhere from 2 weeks, to over a year … This timeline beyond a year for non-shelter based participants helps accommodate ongoing court support and safety planning associated with the changing situation due to court outcomes.

CTI could be relevant based on the scope of the outreach worker. For outreach workers whose scope of practice includes court support and/or safety planning surrounding court support and outcomes, the CTI model would not be relevant due to the timeline needed beyond 9 months. The role of an outreach worker is transitional in terms of connecting to resources for mental health, income, food, housing, childcare, and social networks, but outreach workers are long-term support where court is concerned.

In theory, and from the research, it looks like CTI is great due to its intentionality in establishing relevant long-term supports for the participant, and the gradual transition from intensive support to support from an arm’s length – giving the participant greater confidence and independence. I like this thought. The struggle from my perspective would be how to fit that in along with court support and safety planning being part of the scope of practice for a worker in a court system that can take over a year to get through. One may ask if the model could be implemented after court is over, or started in-shelter and then continued out of shelter to accommodate 3 month post-shelter maximum service delivery time periods, but it seems like that wouldn’t be a true CTI model in practice.

The success of CTI also depends, crucially, on the state of collaborations amongst the primary provider of CTI and additional support services, as well as on the accessibility of such supports in the community. The hurdle here is that the anti-violence service sector, notwithstanding its incessant paeans to collaboration, is rife with territoriality over mandates and concern over burdens on staff. Suspicion and lack of collaboration amongst agencies hampers referrals and hurts help-seekers; hinders development of knowledge bases; hinders the creation and use of platforms for developing and sharing competencies; loses the power of joint efforts. On the brighter side, some Edmonton service agencies act on the understanding that collaboration is vital to make the best of scarce resources and a new approach in this regard is to create capacity by creating and sustaining ‘relentless connections.’ Collaborative groups that meet regularly, with email reminders and updates to members, invitations to present ongoing work are valuable because information sharing prevents duplication of work, improves direction of effort, saves time, and generates creative solutions for complex problems. Examples are case consultation groups that bring together frontline workers and case managers (from non-profits and government agencies), academics, and other relevant discussants. Physical collocation of agencies is also a step towards regular interaction, joint participation in training programs, pooling of expertise on similar cases experienced in different agencies, and appropriately directed referrals. The looming questions here are the time (and money) available to participants and the incentives needed to maintain the sense of investment of various stakeholders in making and sustaining these connections.

What are some ways of coping with a mismatch between agency tradition and/or expectations and CTI model?

Sometimes a conflict emerges between agency expectations and fidelity to the CTI model. It is essential that prior to implementing CTI, administrators are oriented to the model and have a thorough understanding of how it can be properly executed within their agency. Some core components of the model should always be adapted to the particular context of the agency, but most are non-negotiable (i.e. substantial changes may threaten fidelity to the model).

How can CTI programs best collaborate with and educate their partnering organizations (agencies to which clients are linked) about CTI?

The head of the CTI program should consider convening meetings with administrators and top clinical staff of partnering agencies to educate them about the model and discuss potential concerns and conflicts. This should be followed by a meeting with their front line staff to provide an overview of the model and answer any remaining questions. Some organizations have found it useful to host a CTI “kick-off” event, which can provide a platform for many partnering organizations to come together to learn about what the model is and is not.

https://www.criticaltime.org/cti-model/cti-implementation-faqs/

Funding is and will remain the biggest hurdle of all for any kind of case work and case management, whether that involves short term CTI or long-term management and outreach. Staff at anti-violence service agencies work around a non-stop roulette of resource constraints, budget cuts, and prospects of layoff. They are often overworked and compassion-fatigued, with burnout itself being a predictor for turnover. Funding challenges mean staff layoffs, re-hires, re-training, and re-establishment of worker-client relationships – all of which present challenges to the continuity of care and to the relationships that shape how care is given, received and used. Even if CTI involves a relatively brief 9-month period, funding-related staff turnovers mean transitions within a transition. For the client being shunted amongst case workers, it means losing the relational and communicative links that facilitate the whole process of transition management. The other implication is that endemic staff shortages enhance existing caseloads, which means fewer hours and staff for CTI implementation. The inter-agency collaborative exchanges that are integral to CTI are also weakened when staff turnover and staff shortages impact inter-agency linkages and quality of communication.

Conclusion

Throughout the difficult process of transitioning out of abuse into emergency shelter, into second-stage shelter and finally into independent living, there is a priority need for continued connections between the client and a case worker. Given the severe resource constraints and short-termism of the service landscape, CTI could be a time-bound measure that could be compatible with ‘optimal resource use’ while enabling a survivor to move to independence in a planned and phased manner.

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