Developing Community Support for Homeless People with Mental Illness: An Analysis of Critical Time Intervention Practices

Background: Maintaining housing stability in the community after institutionalization depends largely on community support. However, developing such support could be a daunting task for homeless people with mental illness. Critical Time Intervention (CTI), an evidence-based program effective in reducing homelessness in a 9-month transition from institutional to community living, focuses not only on providing emotional and practical support but also on developing clients' long-term ties to the community. This grounded theory study aims to generate a framework of CTI workers' practice of developing community support and identify their practice strategies. This research informs community mental health practices that help to enhance continuity of care and break the vicious cycle between institutionalization and homelessness.

Methods: The study involved twelve participants, including clinical staff from a clinical trial study and workers from all four community agencies providing CTI services in the target city at the time of study. They varied in their racial and educational backgrounds, age (26 – 55 years), and time in the current position (0.8 – 10 years). Data were collected through semi-structured, one-on-one, audio-taped, 40-90 minute-long interviews with the principal investigator. The initial interviews involved broad, open-ended questions which then evolved on the basis of ongoing analysis for each subsequent interview to solicit most relevant data for the conceptualization of CTI practices. Verbatim transcripts were analyzed line-by-line by using dimensional analysis procedures to identify and conceptualize key elements that altered CTI workers' practices with clients.

Results: Results show that CTI workers recognized their time-limited involvement with a client and sought to identify an individual who would take the primary care responsibility for the client after CTI ended. They utilized a transient triangular relationship model to develop community support in which they self-identified as “extra support.” The model indicates three dyadic (worker-client, worker-primary support, primary support-client) relationships as the building blocks and specific strategies utilized to facilitate progress. The worker first developed a trusting working relationship with the client prior to making the transition to the community. The worker-client relationship was fundamental to developing the worker-primary support relationship as the worker was able to establish his or her credibility by sharing in-depth knowledge of the client, in addition to employing relational skills to connect with the primary support. Built on the worker-client and worker-primary support relationships, the worker used strategies to strengthen client confidence in the primary support and the client's enhanced abilities and to provide consultation to the primary support. Eventually, the worker fostered a primary support-client relationship featuring open communication and the primary support's understanding and acceptance of the client, to help maintain clients' housing stability.

Conclusions: CTI workers adopted a specific bridging role in this transient triangular relationship model to help clients develop community support in an effective and efficient fashion. Discussion focuses on the difference between this bridging role and the brokerage function in case management, the specific strategies to navigate through the three dyadic relationships, the influences of CTI structure on this practice, and applications in broad community mental health practices.