CLINICAL HANDBOOK OF SCHIZOPHRENIA

40. Housing Instability and Homelessness 417ter client dependency. An important challenge to psychiatric providers on clinical and administrativelevels is to identify which consumers need longer term intensive services, andwhich may benefit from a time-limited intervention during a critical time, or times, in theconsumer’s life. Furthermore, resource limitations in some localities have caused a numberof ACT teams to shift to time-limited interventions, allowing clients to “graduate”from the program, similar to CTI, described below.CRITICAL TIME INTERVENTIONAs one of the McKinney demonstration projects developed in the late 1980s, CTIadopted some of the ACT principles, yet introduced novel approaches to preventing recurrenthomelessness in a time-limited (9-month) intervention. CTI assumed that therewould be a “critical period” of transition from shelter life to community-based housingfor a population of homeless men with SMI leaving a large New York City shelter. LikeACT, CTI utilized an assertive team case management approach that included a nurseand psychiatrist working with a primary case manager. However, CTI aimed specificallyto reduce homelessness by focusing on several risk areas: medication adherence, substanceabuse treatment, family psychoeducation, prevention of housing-related crises,and money management. Yet for a given client, only one or two of the most significantrisk areas would become the focus of the intervention. In addition, informal, communitybasedskills training was ongoing throughout the phased 9-month intervention. The timelimitednature of the intervention, another departure from the prevailing philosophy ofACT at that time, necessitated a reduction in the intensity of direct services by the teamover the three phases of CTI. The first phase, “Transition to the Community” is most likeACT, involving at least weekly visits and very active direct care by a CTI worker, typicallyan experienced but not professionally trained individual working under professional supervision.The second phase, “Try-Out,” involves a stepping back by the CTI worker, agrowing reliance on linkages to community supports and on the client’s own skills, andactive intervention by the worker only as needed. In this phase CTI is probably best describedas a hybrid of assertive and linkage approaches. In the final phase, “Transfer ofCare,” the CTI worker mostly observes and troubleshoots to fine-tune the communitylinkages. In this phase, a formal termination process is crucial, perhaps marked by ashared meal and review of the client’s progress.The effectiveness of CTI has now been studied in a number of randomized clinicaltrials. Findings from the initial CTI study (see References and Recommended Readings)include a significant reduction in homelessness that lasted at least 9 months beyond theintervention itself, a reduction in negative and autistic symptoms, and evidence of costeffectiveness.Current CTI adaptations include a variety of populations and settings, suchas men and women with SMI discharged from inpatient psychiatric treatment, mentallyill persons discharged from prisons, homeless mothers with mental illness transferredfrom shelters into transitional housing, and homeless mentally ill veterans treated by dedicatedhomeless outreach teams. CTI has recently been recognized as a model program bythe President’s New Freedom Commission on Mental Health and by the Substance Abuseand Mental Health Services Administration.HOUSING APPROACHESMuch debate exists as to what types of housing approaches are most effective for homelesspersons with SMI and at what point in the treatment process housing should be in-