Co-Occurring Disorders and Homelessness
Components of Critical Time Intervention
Critical Time Intervention begins before the transition from an institution to the community takes place. The practitioner forms a relationship and establishes trust with the individual with co-occurring disorder in the institution. From there, three distinct phases begin:
1. Transition to the community
3. Transfer of care
Each phase is time-limited.
As outlined in the table below, each phase takes roughly three months each, spanning a total of nine months after the person leaves the institution or is placed into housing. Throughout each phase, the goal is to establish community linkages. These linkages are made with housing providers, treatment providers, rehabilitative programs, family, clergy, consumer advocates, and peers-anyone in the community who can help the person achieve housing stability and an improved quality of life.
|Table 1. Phases and Activities of Critical Time Intervention|
|Phase||One: Transition||Two: Tryout||Three: Transfer of Care|
|Timing||Months 1 - 3||Months 4 - 6||Months 7 - 9|
|Purpose||Provide specialized support and implement transition plan||Focus on problem solving skills||Terminate critical time intervention services with support network safely in place|
Practitioners make home visits
Accompanies person to community providers
Meets with caregivers
Substitutes for caregivers when necessary
Gives support to person and caregivers
Mediates conflicts between person and caregivers
Practitioners observe operation of support network
Helps to modify network as necessary
Practitioners reaffirm roles of support network members
Develops and begins to set in motion plan for long-term goals (e.g., employment, education, family reunification)
Holds a party or meeting to symbolize transfer of care
Phase 1: Transition to the Community
Phase 1 focuses on providing intensive support and assessing available resources for the transition of care to community providers. Typically, the practitioner begins working with the individual before discharge. During the first few weeks following discharge, the practitioner builds on this relationship and maintains a high level of contact through telephone calls and home visits. To ensure that services are not interrupted during this critical time, the practitioner can arrange interim mental health and substance abuse services and access to medication until community arrangements are in place.
Meeting Community Providers
During phase 1, the practitioner also accompanies the individual to appointments with community providers, such as mental health and substance abuse facilities and medical clinics. This facilitates the development of a lasting relationship and encourages negotiation of problems, should they arise. During the transition phase, the practitioner also coaches individuals, strengthening their ability to advocate for themselves.
Getting Settled in a New Residence
The practitioner escorts the person to his or her new residence and visits regularly to support the person's adjustment to community living. The practitioner meets with key persons in the person's residence-usually the primary caretaker in a family home, staff in a supervised residence, or a single-room occupancy hotel manager. During these meetings, the practitioner helps negotiate ground rules for relationships. They discuss issues that may arise and identify ways to avoid anticipated problems. They may also develop coping strategies and resources in the event of a crisis. The practitioner mediates compromises, if necessary. Compromises developed during this early phase of transition may avert later loss of housing.
Meetings With Family Members and Practitioners
During Phase I, the practitioner brings together the individual with co-occurring disorder, family members, and other service practitioners to detail proposed arrangements. The meetings focus on the areas that are most critical for the person's survival in the community and ability to maintain housing.
Examples of critical concerns include medication adherence, money management, or control of substance use. The worker may teach skills for crisis resolution or provide family members with information about co-occurring disorders.
Phase 2: Tryout
Phase 2 is about testing and adjusting the support systems that were developed in Phase 1. The basic system should be in place, and the practitioner and individual focus on problem-solving skills and exploring the capacity of the support system. Meetings with the individual are less frequent, but contact is regular. It is important to observe how the plan is working and be ready to intervene should a crisis occur.
Community Service Practitioners Take the Lead
During Phase 2, community service practitioners assume the lead role in providing services and support. The critical time intervention team encourages the individual and his or her supporters to manage problems on their own. The team remains a primary resource for all parties, assisting them in creating a framework for resolving potential conflicts. When the system seems to operate smoothly, the team can become less active in the case. Mediation, advocacy, modification of the support system, or renegotiation of treatment plans may be needed.
Phase 3: Transfer of Care
Phase 3 focuses on completing the transfer of support to community resources that will be available to the individual for the long-term. During this phase, the key issue is dealing with the end of the critical time intervention.
One way critical time intervention differs from other services is that the transfer of care process is not abrupt. The transfer takes place in stages over the nine months. Throughout the intervention the practitioner gradually reduces his or her role in delivering direct services.
Reviewing Progress and Long-Term Goals
In Phase 3, one to two months before the end of the intervention, the practitioner, person, and the most significant members of the support network meet to reach consensus about the components of the ongoing system of care. They discuss the transfer of care and review long-term goals, allowing time to troubleshoot any difficulties.
The individual and the practitioner review the work they have done together. They note where the person was at the beginning of the process, movement during the transition, and the possibilities ahead. They discuss the person's skills, strengths, vulnerabilities, and the supports that are in place.
Measuring process ensures that the end of critical time intervention is not regarded as an unexpected, potentially traumatic, loss. A meeting or celebration at this time is a good way to formally recognize the end of the intervention and the relationship.
Resources and Links
This user-friendly manual reviews the theoretical background and forerunners of the critical time intervention treatment model; covers areas of intervention and critical time intervention's clinical principles; goes into depth about the three phases of the model; provides clinical examples; and outlines how to start a critical time intervention program.
On March, 22, 2011, Daniel Herman, DSW, Associate Professor of Clinical Epidemiology at Columbia University's Mailman School of Public Health, gave a guest lecture entitled "Critical Time Intervention: An Empirically Supported Model for Preventing Homelessness in High Risk Groups." Dr. Herman leads research and dissemination activities pertaining to critical time intervention, a time-limited psychosocial intervention intended to prevent homelessness and other adverse outcomes among adults with severe mental disorders.
This web-based training offers basic knowledge and explores the phases of critical time intervention, the role of the team, and the research that supports this evidence-based practice. The course, which users complete at their own pace, features illustrated slides, background readings, audio and video clips, activities, and quiz questions. Continuing education credits are available.