A Worker-Client Relationship That Helps to Reduce Recurrent Homelessness Among People with Severe Mental Illness: An Analysis of Critical Time Intervention Practices

Background: Critical Time Intervention (CTI), an evidence-based community psychosocial intervention, effectively reduces recurrent homelessness among people with severe mental illness by enhancing continuity of care during the transition from institutional to community living. CTI is a 9-month long program during which a designated practitioner works with a client through three sequenced, transitional phases. This paper explores the CTI workers' viewpoints on the relationship workers develop with clients in order to realize the goal of maintaining community residency, and how the relationship influences clients' motivation for stable housing.

Methods: For this grounded theory study we recruited twelve CTI workers, including clinical staff from a clinical trial study and practitioners from four community agencies providing CTI in New York City. All of them had been trained by CTI model developers. We conducted semi-structured, one-on-one interviews. The initial interviews involved broad, open-ended questions that evolved on the basis of ongoing analysis for each subsequent interview to facilitate collection of the most relevant data for conceptualizing the worker-client relationship development. We applied dimensional analysis procedures on verbatim transcripts to identify and conceptualize key elements involved in CTI workers' practices with clients.

Results: CTI workers perceived that the goal of CTI was not only to obtain but to retain housing, and it was essential that clients shared the same goal. CTI workers viewed a humanistic and trusting worker-client relationship as important in working with clients, who varied in their initial motivation for obtaining and retaining housing. We identified three intertwined processes in the relationship development. In "engaging clients," workers consciously fostered a humanistic, non-authoritative relationship, and emphasized the importance of relating to clients in "informal" ways, such as chit-chatting, going out for coffee, and approaching clients as a friend. We found that workers viewed clients as the primary source of information when getting to "know the client." Workers indicated that informal relating approaches and active listening helped facilitate communication with clients, and that better engagement led to more detailed and accurate client-proffered information. In "taking the client's lead," workers maximized the extent to which they followed clients' pace in the process. The trust established within the working relationship helped the worker to gradually take a directive role while solidifying the bond with the client. The worker then was able to gear the direction of the client's efforts to ultimately involve housing. We further identified that the relationship facilitated housing stability through its impact on client motivation for housing. It kept clients motivated in difficult times during the transition. Moreover, it might motivate clients who reported having no interest in housing to accept and work for stable housing.

Conclusions and Implications: A humanistic, non-authoritative worker-client relationship was instrumental in CTI practices aiming at reducing recurrent homelessness. While running counter to traditional notions of boundaries in therapeutic relationships, the relationship benefits this particular population that is among the most socially marginalized and economically disadvantaged. We discussed the developmental strategies of this relationship and their applications in broader community mental health practices.