Critical Time Intervention: Offering What’s Most Needed, Now
A program being piloted in Orange and Chatham counties helps people recovering from mental health crises to get what they need, when they need it.
By Taylor Sisk
One o’clock on a Wednesday afternoon, and a spirited game of bingo is waging in the lobby of Carolina Springs Apartments, a senior citizen community in Carrboro.
Jack Gregory declines to participate.
Not that he has anything inherently against it, but Gregory, 67, isn’t quite ready for bingo, and certainly not for shuffleboard. Today he feels like a teenager.
“I’m thinking about my future,” he said, seated upstairs in his new apartment. He’s asking himself in this moment, “‘What do you want to do with your life, Jack?’”
There were other, more immediate questions on Gregory’s mind throughout four days in a homeless shelter, and during his most recent stay in the UNC Hospitals psychiatric ward. (Was that his third stint there, or fourth? He can’t rightly recall.)
But today he’s on his feet and facing the future. Gregory credits a program called Critical Time Intervention.
Critical Time Intervention
CTI was developed in New York City to help people living with mental illness transition from hospitals, incarceration or homelessness into living back in the community. It links these individuals with essential services – housing, medical and psychiatric care, substance-abuse treatment – and offers practical and emotional support.
These are folks with complex needs; many have untreated mental, substance-abuse and medical issues. Their common need is assistance through a critical transition. CTI is hands-on and immediate. It’s about providing what’s most needed in the moment, and adapting as the situation dictates.
“[People] can get rapidly engaged, get into good resources,” said Annie Kelly, a fourth-year psychiatry resident at UNC who’s working with the CTI project, “and then start that process of transitioning to more permanent support.
“I think CTI is really meeting a need in the mental health system that otherwise is not being met.”
In July 2012, the Kate B. Reynolds Charitable Trust awarded social worker Bebe Smith a three-year, $567,000 grant to introduce CTI in Orange and Chatham counties.
At the time, Smith was co-director of the UNC Center for Excellence in Community Mental Health. She’s now a clinical assistant professor of social work and psychiatry in UNC’s School of Social Work, and the CTI project is being administered collaboratively by the Center for Excellence and the School of Social Work.
Smith has worked with a bevy of local agencies to identify and approach individuals most in need of the help CTI provides. These agencies include the Community Empowerment Fund, Housing for New Hope, the Orange County Partnership for Homelessness, Cardinal Innovations and law enforcement.
“PTSD doesn’t take any prisoners,” Gregory said. Post-traumatic stress disorder pretty well destroyed his life.
Born and raised in Miami, Gregory enlisted in the Army in 1963, directly out of high school and into Viet Nam, a helicopter pilot.
He served four tours in Viet Nam, a total of 51 months, cycling back in as quickly as they’d allow him. He took early retirement in 1977; having earned a degree in broadcast journalism from American University, he came to the Triangle and worked as a TV sports anchor.
There was no PTSD, per se, in those days, Gregory said. “It was just ‘shell-shocked.’”
He struggled with the transition to civilian life, and reenlisted.
Much of the nineties are a blur. He lost his family, work. In 2001, he began getting treatment at UNC. His PTSD was manifesting itself in flashbacks and depression. Then, Gregory was diagnosed as bi-polar. In 2006, he began electroconvulsive therapy.
A couple of years ago, Gregory met a woman online, a former member of the Army Medical Corps who said she’d take care of him, and moved to Florida to be with her. It was, he now says, a fiasco. He returned to the Triangle.
“I had nothing,” he said. “I was flat on my back with depression.”
Readmitted to the hospital, he pleaded with UNC to help him get back on his feet. Upon release, he had nowhere to go.
Gregory was an ideal candidate for Critical Time Intervention: He needed help now. He fell into the category of those Smith refers to as being “out there,” unconnected to services in their communities.
Helping these individuals is a matter of linking them with a variety of agencies and, most fundamentally, getting them into housing, a base from which they can begin to rebuild.
“It’s a housing-first model,” Smith said. “You need a base from which to begin to address other needs. If your basic needs aren’t met, you can’t begin to address any of the other things.”
Nick Lemmon, a social worker and CTI team member, helped, in Gregory’s words, “put the package together.”
Gregory had veterans’ benefits and social security, but not the wherewithal to take it all and create a life for himself.
“At the time, when I wasn’t able to do that, they were there,” he said. “And if they hadn’t been, that four days in the homeless shelter might well have been four weeks, or four months. Or then what? Who knows?
“Maybe my PTSD would have told me it’s time I get crazy and do something really stupid. Who knows what could have happened?”
“That’s how desperate those times were for me,” Gregory said.
This three-year, grant-funded CTI project is designed to first implement the program locally. Then the plan is to champion CTI statewide, get the word out and work with legislators in hopes of seeing it more broadly implemented.
The program is time-limited – clients remain in it for a maximum of nine months – and is mapped in three phases.
The first phase is to connect, determine the most immediate needs and find solutions to those needs. Next is to help the client become more self-sustaining. Phase three is the transition to what comes next: work, school, ongoing therapy, medical care, whatever the situation dictates.
“You pull out and step back in as needed,” said CTI team leader Janice Bainbridge.
CTI has no set rules, Bainbridge said, which makes it different. Other treatments require that the client sign up, agree to participate in an assessment, set goals and so forth.
“We invite people to do that,” she said.
But many of her clients, when first encountered, aren’t ready. First, Bainbridge must build relationships with people who are emotionally fragile and whose lives have fallen apart. Many have no identification, have lost their birth certificates, are estranged from all support.
“It’s really a matter of starting from scratch,” Bainbridge said.
Gregory calls it “a partnership.”
The program has received 60 or so referrals and is working actively with about half of those people.
The transition from homelessness to home can be difficult.
Amanda (who asked that her last name not be used) had been essentially homeless for years, having set out on her own as a teen.
“I was a complicated kid,” she said. “I was very grownup, and I was forced to be because I was abused by my stepmom. Every night, she would come and whip me across the back with hangers, anything she could get her hands on, for anything – any misdeed.
“If I left a sweater on the floor, I was whipped.”
With a succession of abusive men, Amanda traveled the country. Most recently, she had been living alone in a tent in a patch of Carrboro woods. Homelessness was her way of life. Not, she acknowledges, a healthy one – but a lifestyle nonetheless.
Amanda’s days were occupied with how she and her cats would eat, stay warm and be safe. And, though she had a community of sorts on the street, she didn’t really have to talk to anyone if she didn’t want to.
With a home come bills, rules, maintenance and neighbors.
Amanda now has those things.
Smith helped her find an apartment in Chapel Hill, and helped her get set up. The bed they placed in that apartment was a Posturepedic, but Amanda couldn’t get the knack of sleeping on it. It was too comfortable. For a month and a half, she slept on the couch.
One of Amanda’s cats, Dante, couldn’t deal with the transition to home life, and hightailed it back to the woods. But Gypsy’s made the adjustment. She sits in the window and stares out, showing no inclination to exit.
“She’s stuck with me,” Amanda said. “She’s a mama’s girl.”
Today things are mostly good. Smith and Amanda have built a relationship. They’ll meet perhaps twice a month, go to the grocery store and catch up on things. And they’ll talk on the phone from time to time.
Smith has been “on the front, fighting for the things that I needed,” she said, and also her “voice of reason.”
Amanda wants to return to school; she wants to be a medical assistant. “My intentions are always good,” she said, but sometimes she loses momentum.
Smith, she said, has helped her manage her goals.
“Success is sometimes just progress,” said CTI team leader Janice Bainbridge. Sometimes progress is simple things.
“Like this guy yesterday,” she said, who really wanted to do his laundry. “If your clothes are dirty, you want clean clothes. If you’re hungry, you want something to eat. If you need to call somebody, you want to call somebody. If you’re cold, you want to be warm.”
Sometimes all that must come before even broaching the subject of housing.
Bainbridge’s work is about “human-being-to-human-being” contact, communication, compassion – about meeting fundamental, everyday needs, the foundation for moving forward.
Smith said CTI has a solid evidence base in reducing nights of homelessness and hospitalizations. Now they’re beginning to look at other outcomes – reduced mental health symptoms, for example.
There’s clear evidence – in the faces of Gregory and Amanda – that it works.
“It can happen,” Gregory said of finding one’s self way down and out. “It happened to me. I was just blessed that I was able to come in contact with the right folks here.”
It’s a process. There are days when Amanda returns to her home, and it hits her: This is me; this is life.
“And it’s at that time,” she said, “that you have to sit back and deal with yourself, and your demons, and things that scare you, and issues that you’ve had that you haven’t had time to concentrate on, because you were surviving.
“Now you’re living; now you have to deal with these issues. And sometimes it gets a bit much. Sometimes I go into depression.
“But I have a network,” she said.
“I consider them family, just as surely as if they were brothers and sisters,” Gregory said of his CTI team “They saved my life. They came in at the most critical moment of my life … when I could have gone in so many different directions without the right people being in place.
“It could have been a whole different ending.”