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The key principles in defining a whole systems approach to respond to a critical time in a person’s life (before or during a crisis) are:
- recognition of a dramatic emotional or circumstantial upheaval in a person’s life that should lead to recovery and not a path of deterioration
- a critical time for reflection and positive growth, self determination – not a time for continuing pathways of hopelessness and /or maintenance
- a time for change for the person to look at their life as a whole not just their mental health problem
- the causes of a crisis need different solutions from various sources, financial difficulties, physical health, work stress, environmental factors, family problems etc.
- the contact and relationship formed between the user and professional in one part of the service should be the same trusting therapeutic relationship in all parts of the service system
These principles are difficult to realise if there is an incomplete whole service system in its design, approach and operation.
- System thinking are a discipline for seeing wholes not holes.
- Its essential framework is developing inter dependence and interrelationships rather than static and separate parts.
- The common purpose of the whole should embrace all the principles of recovery and whole life and the parts of the system must be sensitive to their contribution in achieving the overall purpose.
- They should actively promote recovery, self determination and growth for the individual by benefiting from both the mental health whole systems service and a community’s natural resources and contributions to form a community whole life-whole system.
Community based alternatives to in-patient hospital care
Research has shown that hospital care is not always necessary or helpful to people experiencing an acute crisis.
The experience for users in acute in-patient units is sometimes not a positive or therapeutic experience and very often does not give the user the time or space to reflect on what is happening to them in their life as a whole.
Many people have repeatedly asked for community based, small scale,personal,less restrictive, therapeutic alternatives.
As a result of implementing the National Service Framework and functional teams some people are able to manage their crisis in community mental health teams and /or home treatment/crisis teams.
However many more are still being admitted to acute units and far to many as readmissions and under compulsory admission.
For these this cycle of hopelessness and maintenance needs to be broken if recovery for the person is going to be a reality.
Over the last few years some places around the world have designed and started to implement community alternatives that look far more encouraging as good models that can offer new hope to users.
The range of these alternatives include:
Crisis Resolution Teams (Home Treatment Teams)
These should provide 24 hours, 7 day a week alternative home based treatment and support for intensive intervention as long as there is a need for the management of the crisis at home to prevent admission
These have been developed as a more homely, small scale residential alternative to hospital care.In some places these have been provided for specific groups,women, minority ethnic groups etc.
Crisis Respite Service
These are informal non-residential short term alternatives. They have been provided in hotels,guest houses or supported accommodation. They are usually managed and supported by community mental health centre staff.
User Run Crisis Houses
These are also referred to as peer – run crisis houses.
They have a strong recovery and natural self help ethos.
They are managed and run mainly by service users.
They provide many alternative coping strategies for self determination, massage, counselling, skills training, meditation, reinforcing responsibility etc. They reach out to encompass the natural resources of the individual and their community.
These are based on the experience of adult fostering schemes but take this forward to provide a natural family support structure for individuals during their acute crisis. Sometimes they are also used to place people in order to prevent a crisis.
Users record a very positive experience from these and they are highly valued by the host family and mental health professionals.
24 hour Community Mental Health Centres with acute beds
This model combines the functions of a Community Mental Health Center/ Home Treatment Service and acute/respite beds in one non-hospital setting.
It has been found to be successful in providing continuity of care, ensuring responsibility to a specific community for the holistic care of individuals and much preferred by users and carers as well as integrated with and highly regarded by local people.
Telephone help line have been shown to provide essential support to people who are experiencing a dramatic or traumatic experience in their lives.
Some of these are provided by NGO’s and others are part of a CMHC service.
Some places have developed initiatives that users have found useful, such as:
Advance treatment/care directives. Users express and record their views and wishes on treatment they do not wish to receive when they are in a crisis
User crisis card / joint crisis cards. These are on cards formally written and agreed wishes of a user themselves or between a user and professional. They can be kept on the person and presented to any service when necessary.
Relapse signature. Using a person centred plan for the user and friends and family to recognise the unique circumstances of the triggers of a relapse and how to prevent it.
In some places in the world some models have been develop by individuals in counties. Some of these have been replicated in other countries.
Soteria Recovery House
These were founded by Loren Mosher in the USA based on providing small scale therapeutic, humane, recovery support for people experiencing an acute psychosis.
They have also been developed in Alaska. Switzerland, Germany, Sweden, Budapest and Denmark.
This was established in Boulder, Colorado. It is an alternative to hospital care and runs as a therapeutic community giving responsibility to the “guests” whose stay is no longer than 10-15 days.
Research into these alternatives have shown similar or better outcomes for service users including improved satisfaction. They have also demonstrated reduced admissions and re-admission rates.
Some of these alternatives should be considered to be developed to form a whole system approach in acute and crisis services. Experience and research has shown that adopting some of these can improve people’s mental health and recovery and reduce significantly the need for expensive hospital beds and in some places do without them completely.
Crisis Services: Effectiveness, Cost-Effectiveness, and Funding Strategies Substance Abuse Mental Health Services Administration, 2014, USA Crisis Services are a continuum of services that are provided to individuals experiencing a psychiatric emergency. The primary goal of these services is to stabilize and improve psychological symptoms of distress and to engage individuals in an appropriate treatment service to address the problem that led to the crisis. Core crisis services include: 23-hour crisis stabilization/observation beds, short term crisis residential services and crisis stabilization, mobile crisis services, 24/7 crisis hotlines, warm lines, psychiatric advance directive statements, and peer crisis services. The research base on the effectiveness of crisis services is growing. There is evidence that crisis stabilization, community-based residential crisis care, and mobile crisis services can divert individuals from unnecessary hospitalizations and ensure the least restrictive treatment option is available to people experiencing behavioral health crises. Additionally, a continuum of crisis services can assist in reducing costs for psychiatric hospitalization, without negatively impacting clinical outcomes. Our environmental scan revealed that most states provide a continuum of crisis services including residential, mobile crisis, and hotlines. Additional core crisis services are available in some states, including warm lines, crisis respite, and crisis intervention teams, depending upon available funding, state and local infrastructure, and state program and funding polices. In our interviews with states, states reported using several different strategies in the provision of crisis services including co-locating different crisis services in facilities that covered a specific geographic region, including trained mental health consumers (i.e. peers) in the provision of crisis services and collaborating with other partners, such as law enforcement. Our interviews also revealed states are providing services using different payment mechanisms. Some states such as Massachusetts, Tennessee and Michigan have used Medicaid managed care waivers to expand their crisis services continuum, while other states have used purchasing contracts and collaborative relationships with other partners to support the crisis services continuum. The most frequently reported funding sources for crisis services are state and county general funds and Medicaid. Although states finance crisis services in different ways, many are using multiple funding sources to ensure that a continuum of crisis care can be provided to all who present for services, regardless of insurance status. Each of the states indicated that using funding from multiple sources has been an effective way to support a continuum of crisis care. States reported opportunities, challenges and lessons learned in implementing and financing crisis services. Opportunities included updating consumer information to streamline identification of payer source, including peers in various roles in the provision of crisis services and collaborating with other partners to improve crisis services. Challenges included difficulties in obtaining reimbursement for crisis services to individuals with dual mental health and substance abuse disorders and difficulties in obtaining crisis services reimbursement from private insurance due to differences in provider qualifications from Medicaid. Finally, states provided valuable insight into lessons learned regarding providing crisis services. Some states reported that they were able to use the flexibility of Medicaid waivers to increase the provision of crisis services tailored to their specific delivery system while other states have used purchasing contracts and collaborative relationships with other partners to support the crisis services continuum. Particularly, states with Medicaid managed care behavioral health carve outs were better able to create a full continuum of crisis services whereas states that operated under the Medicaid fee-for-service model faced challenges in implementing a full complement of crisis services. States also emphasized the value of collecting data on crisis services quality indicators to inform policy decisions around crisis care.
Listening to experience: An independent inquiry into acute and crisis mental healthcare Published by Mind, 2011 To look at the whole question of what was happening in acute and crisis care, Mind brought together an independent set of experts and commissioned them to conduct an inquiry into the state of acute care in England and Wales. This report reflects the findings of the panel and forms the basis for Mind’s campaign on acute and crisis care. Acute and crisis mental health services provide for people at their most unwell and vulnerable, when needs are particularly urgent. Recommendations: For commissioners and local health boards: Review how far acute services are meeting local people’s requirements, and consult with black and minority ethnic communities in this process. Set clear standards for values-based services in the procurement or planning process and hold providers to account using measures that include service user/carer satisfaction. Expand the range of options to meet different needs; for example, crisis houses, host families and services provided by people with experience of mental health problems, and self-referral options. For provider organisations: Consider ‘inpatients’ as ‘guests’ as well as recipients of care. Review the standards of hospitality that are being offered and ask the guests for their feedback. Commit to working without violence and reappraise control and restraint methods, in particular ending face-down holds. For staff teams: Carry out jointly negotiated crisis planning with people who may need to access acute care in future. Plan and perform your work in the knowledge that people using services value time with staff and that empathy, kindness and respect go a long way. For professional education providers: Market mental health professions and recruit on the basis of candidates’ values and personal qualities as well as skills. Re-evaluate how professional boundaries are taught so that staff are encouraged to be themselves with the people in their care.
The Abandoned Illness A report by the Schizophrenia Commission 2011 The Schizophrenia Commission was established in November 2011 by Rethink Mental Illness. The independent Commission was made up of 14 experts who have worked together to review how outcomes for people with schizophrenia and psychosis can be improved and it was chaired by the eminent psychiatrist, Professor Sir Robin Murray. The Commission ran six formal evidence gathering sessions involving over 80 experts, including people who have lived with schizophrenia or psychosis, family members and carers, health and social care practitioners and researchers. 2,500 people responded to the Commission’s survey online. The Commissioners also visited services across England and drew upon relevant published research literature. They focused, in particular, on the delivery of adult mental health services but did also consider the impact on young people, those within the criminal justice system, the homeless and those with co-morbid problems such as substance misuse as well as the role of prevention and community development for building an emotionally resilient and healthy society. They found broad agreement about the changes that need to be made to transform the lives of those with schizophrenia or psychosis and of their families. Encouragingly, we also had support from a range of organisations and practitioners for our approach. We are making 42 detailed recommendations which include: Increasing access to psychological therapies in line with NICE guidelines. Delivering effective physical health care to people with severe mental illness by improving the training of all mental health staff as well as monitoring the delivery of routine physical health assessment and intervention. A stronger focus on prevention including clear warnings about the risks of cannabis. Action to address inequalities and meet the needs of all disadvantaged groups. A better deal for long-term carers who should be treated as partners. Greater use of personal budgets, particularly for those with long-term care needs. Psychiatrists must be extremely cautious in making a diagnosis of schizophrenia as it can generate stigma and unwarranted pessimism. The more general term ‘psychosis’ is preferable, at least in the early stages. A radical overhaul of poor acute care units including better use of alternatives to admission like recovery houses to manage the transition between hospital and community services. Greater partnership and shared decisionmaking with service users - valuing their experiences and making their preferences central to a recovery-focused approach adopted by all services. Funding redirected from secure units to strengthen community-based provision and prevention programmes. Clarity about who is in charge of delivering care, tackling poor leadership in our services and variations in the quality of care provided. Much better prescribing and a right to a second opinion on medication involving, where appropriate, a specialist pharmacist. Extending general practitioner training in mental illness to improve support for those with psychosis managed by primary care. Extending the popular Early Intervention for Psychosis services (not cutting or diluting).
Being There in a Crisis A Report of the learning from eight mental health crisis services Mental Health FoundationUpdates 2002 ‘Being There in a Crisis’ is a report of the learning from eight community-based mental health crisis services, produced by the Mental Health Foundation in association with the Sainsbury Centre for Mental Health. The Foundation funded and supported seven crisis services (three telephone helplines, two crisis/safe houses and two residential crisis services) over a period of three years. The Sainsbury Centre for Mental Health (SCMH) evaluated the two residential services and one other service not supported by Mental Health Foundation.
A recovery-oriented alternative to hospital emergency departments for persons in emotional distress: "the living room" Shattell MM, Harris B, Beavers J, Tomlinson SK, Prasek L, Geevarghese S, Emery CL, Heyland M. Issues Mental Health Nursing 2014
Objective: To describe The Living Room, a community crisis respite center that offers individuals in crisis an alternative to obtaining services in an emergency department (ED).Methods: This article describes the problems individuals in a mental health crisis may encounter in traditional EDs and explains how The Living Roomaddresses these problems. The Living Room’s development, setting, staffing and procedures are described in order to promoteincreased use of this type of program.
Results: In its first year of operation, The Living Room hosted 228 visits by 87 distinct individuals (termed “guests”). Guests were deflected from EDs on 213 of those visits – a 93% deflection rate. These deflections represent a savings of approximately $550,000 to the State of Illinois since guests of The Living Room are overwhelmingly individuals with Medicaid or noinsurance of any kind. On 84% (n=192) of the occurrences in which guests were deflected fromEDs, they alleviated their crises sufficiently to decide to leave The Living Room and return to thecommunity. These guests reported an average decrease of 2.13 points on the Subjective Units of Distress Scale.
Conclusions: Community crisis respite centers such as The Living Room represent an importantalternative to EDs by remedying many criticisms of traditional EDs made by individuals incrisis. Outcomes from The Living Room ’s first year of operation suggest that community crisis respite centers are cost-effective, effective in helping many individuals alleviate crises, and havethe potential to decrease the use of EDs for mental health crisis.
The roots of hospital alternative care Richard Warner The British Journal of Psychiatry (2010) 197 British hospital alternatives inherit some of their most valuable features, such as the use of small, domestic environments and the avoidance of coercion and confinement, from the early 19th-century moral management movement. The North American experience illustrates that these advantages can be lost if clinical benefits are overridden by cost and other practical concerns.
Peer Developed Vision of Peer-Run Respites Process and Outcomes of Statewide Listening and Dialog Sessions conducted by Grassroots Empowerment Project, Inc. 2012 In June 2013, Grassroots Empowerment Project was awarded a BRSS TACS Peer Award for a proposal to facilitate peer engagement in the development of peer-run respites in Wisconsin. Throughout this process it has been clear that peers across the state embrace the addition of peer-run respites and have strong views on what they need and want in a peer-run respite. Their visioning included what they saw as essential to peer-run respites, what they saw as contrary to the concept of peer-run respites, and what they saw as important issues needing further statewide peer engagement. This report includes:
- A brief description of the process activities carried out to engage peers statewide
- An outline of the collective vision, which includes specific peer-developed definitions ofthe elements of peer-run respites, such as Peer and Peer-run
These discussions consistently saw the highest engagement and interest while at the same time resulting in the strongest degree of consensusA general outline of other elements that emerged as common and resulted in general agreement
- A list of issues that consistently held strong interest and concern for peers across the state, and that after considerable dialog resulted in a strong consensus that they needed and deserved much more peer dialog and input.
- An outline of the participation and outcomes of participant evaluations
- A brief description on GEP’s work, planned or in progress, on continued statewide engagement of peers
Evaluating Peer-Operated Crisis Care Alternatives Laysha Ostrow, M.P.P. Johns Hopkins Bloomberg School of Public Health Presentation to Columbia University/Nathan Kline Institute, September 2012
- Review of the model of peer-run and -operated crisis respites
- Characteristics of existing respites
- Peer-run respites in the continuum of care and community
- Sustainability: Shifting funding from state/county funds to Medicaid reimbursement
- Research and Evaluation: Results of survey of existing respites
- Recommendations on evaluation
Acute wards: problems and solutions Alternatives to acute wards: users’ perspectives Peter Relton and Phil Thomas Psychiatric Bulletin (2002), 26, 346 - 347 the values and philosophy of care deserve to occupy a central position in our thinking about the nature of statutory services, whether in-patient or an alternative. In directing attention to structures of care, the NSF may, inadvertently, have downplayed the importance of philosophy and values of care. User-led research indicates that non-professional support based on the human values of solidarity and companionship are key alternatives to professional services. There are important lessons in this for the nature of statutory services.
An Emergency Housing Program as an Alternative to Inpatient Treatment for Persons With Severe Mental Illness Renee Goodwin, Ph.D. John S. Lyons, Ph.D. Psychiatric Services, January 2001 Vol. 52 No. 1 This study evaluated the feasibility and effectiveness of an emergency housing program as a step-down program after inpatient care, as a step-up program from community-based living, and as an alternative to inpatient care for individuals with serious mental illness who sought treatment at an urban medical center. Methods: One hundred sixty-one persons admitted consecutively to an emergency housing program were assessed retrospectively with the Severity of Psychiatric Illness scale and the Acuity of Psychiatric Illness scale at admission and again at discharge. Analyses of covariance were used to evaluate the change in residents’ clinical acuity and psychosocial status between admission and discharge. Results: Residents who had been admitted to the emergency housing program from inpatient psychiatric treatment showed a significant decline in acuteness of psychiatric symptoms. Psychiatric symptoms also improved for residents who were admitted to the program from community-based service programs and for residents admitted as an alternative to inpatient treatment, although the differences for these two groups were less prominent. Conclusions: The findings suggest that an emergency housing program is a feasible mode of extended community-based care for many persons with serious and persistent mental illness.
Recovery Oriented Acute and Crisis Services in Trieste
Roberto Mezzina, Director, Department of Mental Health, WHO CC, Trieste, Whole life –whole systems Symposium
21 March 2014, Stevenage, UK
Alternatives to Admission by Rethink Evidence shows that our recovery house model offers a cost-effective alternative to acute admissions and produce comparable outcomes. Carers and people who use services prefer them. A comparison of standard acute inpatient mental health care and alternatives found that alternatives are significantly cheaper – on average £3,832 per admission compared to £9,850 – and more cost-effective - £2,939 cheaper per unit on Health of the Nation Outcome Scales improvement scores, with much shorter average stays. A recent report shows that 27% of respondents rarely feel safe whilst in hospital. A staggering 51% of inpatients report being verbally or physically threatened during their stay, with 20% reporting physical assault and 31% of harassment or assault episodes being perpetrated by ward staff. A study comparing patient satisfaction, ward atmosphere and perceived coercion in community residential alternatives and standard wards, showed those using the alternative services reported greater levels of satisfaction, having more of a ‘voice’, greater autonomy, more support, less anger and aggression, and fewer experiences perceived as coercive.
Crisis Hostel: Alternative to psychiatric hospitalization The Crisis Hostel, located in Ithica, New York, is a place where people who are experiencing an emotional or mental crisis, have an alternative to psychiatric hospitalization. The hostel opened its doors in November 1994 and is part of a two-year research project funded by the Center For Mental Health Services in an effort to show that even when people are in crisis, they are capable and entitled to make their own choices about treatment and healing. The founders of the Crisis Hostel believe that peer counseling can be effective in promoting self-healing and that the option of retreating to a supportive place for a short period of time may enable people to avoid unnecessary or unwanted hospitalization.