History of CTI
In 1990’s New York, social work professor Dan Herman noticed that men who were moving out of communal shelters into permanent housing were cycling back through the shelter system.
Herman found that the point of transition from shelter to community was filled with potential and risk. Without the necessary supports in place, the housing placement could quickly fall apart. With this in mind, Herman and colleagues developed Critical Time Intervention (CTI), a model which is now used across the USA, and the world, to support vulnerable people through periods of transition.
What is CTI
Over the years that followed its initial development, CTI has become defined by a set of 10 principles.
Some of these principles are familiar and feature in other models and interventions, such as Housing First, outreach services and supported housing. However, there are some principles which are very specific to CTI and set the model apart. Two key principles which illustrate this are ‘Designed around a transition’ and a ‘Phased approach.’ CTI can be adapted to many kinds of populations, but it does always apply to a point of transition such as release from prison, discharge from hospital or moving into permanent housing.
- Linking to long-term support
- Small caseloads
- Limited focus
- Decreasing intensity/phased approach
- No early discharge/minimise drop-out
- Community-based
- Designed around a transition
- Harm reduction/recovery oriented
- Frequent case reviews
- Team-based supervision
Evidence
There is compelling evidence about the effectiveness of CTI, most of which comes from the USA due to limited application elsewhere. Over the last three decades, there have been many randomised control trials for CTI, leading to CTI being an evidence-based practice and ranked Top Tier in the USA:
Programs shown in well-conducted RCTs [randomised controlled trials], carried out in typical community settings, to produce sizable, sustained effects on important outcomes. Top Tier evidence includes a requirement for replication – specifically, the demonstration of such effects in two or more RCTs conducted in different implementation sites, or, alternatively, in one large multi-site RCT. Such evidence provides confidence that the program would produce important effects if implemented faithfully in settings and populations similar to those in the original studies. Evidence Based Programs - Social Programs That Work Social Programs That Work
The first trials in the US, were conducted with men experiencing chronic homelessness. CTI interventions saw a 66% increase in tenancy sustainment compared to the control group. In addition, a US wide study with homeless veterans showed that those using CTI were five times more likely to still be housed after 18 months. In the UK, CTI was piloted by an NHS Service for six weeks, to support people leaving prison with severe mental illness. The study concluded:
The intervention significantly improved contact with services at 6 weeks, although at a higher cost than the control (group). This is important as, in the days and weeks following release, recently released individuals are at a particularly high risk of suicide and drug overdose.
Application in the UK
In 2017, Alex Smith took part in Homeless Link’s Transatlantic Practice Exchange and worked with Brilliant Corners in Los Angeles to better understand CTI. Following the exchange, a report was published, which then led to CTI being tested by the Newcastle Gateshead Fulfilling Lives programme. This pilot was fully evaluated and found that the effectiveness of CTI was mixed:
The process of setting goals helped to empower people and encourage them to look positively to their future, and the time limit brought a sense of focus.
However, a time-limited approach was not as successful for people who were experiencing ongoing crisis:
CTI could be usefully considered as (i) a targeted model for a discrete group of people who meet certain criteria around stability and the ability to form relationships; or (ii) the second step in a two-step model for people experiencing MCN [multiple complex needs].
In 2018, Crisis’ How to End Homelessness in Great Britain cited CTI as a key mechanism for ending homelessness, which then lead to Crisis piloting two CTI services. These services included supporting men being released from prison in Merseyside and Swansea as well as a funding ACH to develop a CTI service for newly arrived refugees in Bristol:
Implementing the CTI methodology has led us to re-evaluate our previous support model and inspire us to think of new ways to provide support. CTI helps us place even greater emphasis on the importance of move-on into independent living in the UK. Upon completion of the pilot, we will use the findings to make the model more effective for our refugee service users. We will then roll-out the CTI model across the other three cities in which we operate, providing the most effective refugee integration service for all of our tenants.
Most recently, the NHS Manchester Mental Health Homelessness Team has undergone training with Homeless Link to adopt CTI for their short-term mental health assessment service for people experiencing homelessness in the north-west - https://homeless.org.uk/news/critical-time-intervention-for-societys-most-vulnerable-individuals/.
The worry of short-term
CTI can feel counter-intuitive to those who have worked with people experiencing multiple disadvantages, where we know that open-ended, stickable support works best. It is therefore important to hold in mind that CTI does not replace the need for long-term support with a short-term time-limited alternative but instead has a very specific role, which is to:
- Provide specific support at the point of transition to help a person settle or resettle into their community;
- Focus on understanding, building and strengthening the person’s support network;
- Understand and support the person’s goals, those that are short, medium and long-term;
- Ensure that there is sufficient support in place at the end of the CTI programme, to ensure that long-term needs and goals can be fulfilled.
Like any kind of homelessness intervention, the person and indeed the model, cannot exist in isolation and the success of CTI is therefore based on the wider health and social care context, as well the availability of suitable housing. If, for example, the individual has ongoing and complex support needs but there are no services available for the CTI team to transfer care to, then there is a risk that the CTI service will be unable to achieve its main aims of being a time-limited and phased approach at the point of transition. Based on the evidence and early testing, CTI may have a place in the efforts to end homelessness in the UK and it will be important to keep a close eye on evaluations from current services such as Crisis and the NHS.
Homeless Link has developed a two-day training course including an Introduction to CTI and Implementing a CTI model. Get in touch for more information training@homelesslink.org.uk.
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