The UT Health Living Room: Expanding the Psychiatric Crisis Continuum of Care.

Traditional forms of psychiatric crisis treatment increasingly are being buttressed by services along the Psychiatric Crisis Continuum of Care, such as short-term crisis stabilization services and peer crisis services. The UT Health Living Room (LR) is an outpatient crisis counseling service that adds three promising elements to the Continuum: (1) it integrates outpatient treatment plans into crisis counseling, (2) provides care in a space and with staff who are familiar to patients, and (3) provides training in evidence-based crisis intervention. We examined two-year LR feasibility and outcome data. Mixed-method analyses used longitudinal clinic data and patient self-report measures. Results provide initial support for the feasibility, cost effectiveness and clinical effectiveness of the LR. Limitations include non-blinded ratings, limited experimental control, and simple cost-effectiveness methodology. The UT Living Room is feasible and offers novel elements to help patients in community clinics address emotional crises.

Attending to Persons with Intellectual and/or Other Developmental Disorders in Crisis Settings.

Crisis response is growing across the United States with increasingly broad phone, text, and chat response systems that lead to triaging callers who may be in need of further outreach. This might include deploying a mobile crisis response team and/or referring a caller to a crisis stabilization unit. The information set forth earlier aims to help advance the field and individual practices to ensure that persons with intellectual and/or other developmental disorders receive equivalent care and treatment with information that helps focus on this population's unique features and needs.

Lessons of the Boom: A Playbook for Crisis Centers to Prevent, Survive, and Respond to Active Assailants, Targeted Violence, and Mass Violence.

Modern crisis centers need to be prepared for mass shootings, active assailant incidents, and related forms of targeted violence. While crisis engagement has traditionally been seen as a "right of boom" or post-incident responder, crisis leaders need to prepare their teams to identify people at risk for violence, use tools like Behavioral Threat Assessment and Management to reduce risk in those persons, and prepare their teams for potential incidents in their community. Evidence suggests that acute stressors are a common proximal risk factor for severe violence implying a potential synergy for using crisis services as a tool for prevention of violence.

Mental Health Crisis Responses and (In)Justice: Intrasystem and Intersystem Implications.

Mental health crises among people who are marginalized merit special consideration. These groups are both overserved and underserved by mental health crisis systems: over-represented in acute treatment settings by number while facing inequities in outcomes. The predisposing, precipitating, and perpetuating factors that contribute to crises, however, neither begin nor end with the mental health system. Rather, these factors are multisystemic. As an illustration of this concept, this article highlights select marginalized groups, those that have faced inequities in mental health diagnosis and treatment due to race, medical complexity, age, and criminal justice system involvement.

Youth Crisis: The Current State and Future Directions.

The number of children and youth experiencing behavioral health crisis in the United States is substantially increasing. Currently, there are shortages to home-based and community-based services as well as psychiatric outpatient and inpatient pediatric care, leading to high emergency department utilization. This article introduces a proposed crisis continuum of care, highlights existing evidence, and provides opportunities for further research and advocacy.

Our Wished-for Responses: Recommendations for Creating a Lived and Embodied Sense of Safety During Mental Health Crisis.

BACKGROUND: Medical interventions have a place in crisis support; however, narrow biomedical and risk-driven responses negatively impact people seeking crisis care. With increasing shifts towards involving people with lived experience (service users) in designing services, foregrounding people's desired responses is critical. Accordingly, the aim of the study was to explore the wished-for crisis responses from the perspective of people who have experienced crisis and accessed crisis care. METHOD: Using a hermeneutical phenomenological approach, in-depth interviews were conducted to determine the desired crisis responses of 31 people who self-reported experiencing mental health crises and accessed crisis services at ED, phone lines and/or crisis alternatives. RESULTS: The findings identified wished-for responses that gave a felt and embodied sense of their own safety influenced by a human-to-human response, emotional holding, a place of safety and choice within holistic care. For such responses to be possible, participants identified organising principles, including recognising crisis as meaningful and part of our shared human experience, understanding risk as fluid and a whole-of-community responsibility for responding to crises. CONCLUSION: This paper proposes how insights from people who have experienced crises can be translated into more beneficial crisis care. PATIENT OR CONSUMER CONTRIBUTION: Most authors are in identified lived experience roles. The first author engaged with participants during the recruitment and interviews and was explicit regarding their lived experience. Service users were involved as advisors, providing input throughout the study.

Peer-Run Respite Approaches to Supporting People Experiencing an Emotional Crisis.

Research shows that guests experience peer-run respites as empowering and safe places where they feel more seen, heard, and respected than they do in conventional settings. This column describes the successful and unique processes of peer-run respites that support guests in emotional crisis and facilitate healing. In a discussion informed by their experiences and the literature, the authors examine how peer-run respites differ from conventional psychiatric crisis response services in their basic philosophy: how emotional crisis is understood, the goal of crisis response, how trauma is viewed, the importance of self-determination, power dynamics, and relationality.

Mobile Crisis Services: A Clinician Survey of Current Suicide Prevention Practices and Barriers to Care Delivery.

Mobile crisis teams (MCTs) deploy clinicians to assist individuals in acute crisis in the community. Little is known about the extent to which these teams provide evidence-based practices (EBPs) for suicide prevention nor the barriers they face. We surveyed 120 MCT clinicians across the United States about their: (1) use of suicide risk screening and assessment tools; (2) strategies used to address suicide risk (both EBPs and non-EBPs); and (3) perceived barriers to high-quality MCT services. Nearly all clinicians reported use of validated suicide screening tools and generic "safety planning." However, a sizeable minority also reported use of non-EBPs. Open-ended responses suggested many client/family-, clinician-, and systems-level barriers to MCT use of EBPs for suicide prevention. We identified several targets for future implementation efforts, including the need for de-implementation strategies to reduce use of ineffective and potentially harmful practices, and unique aspects of MCTs that require tailored implementation supports.

Explanation of context, mechanisms and outcomes in adult community mental health crisis care: the MH-CREST realist evidence synthesis.

Background: Mental health crises cause significant disruption to individuals and families and can be life-threatening. The large number of community crisis services operating in an inter-agency landscape complicates access to help. It is unclear which underpinning mechanisms of crisis care work, for whom and in which circumstances. Aim: The aim was to identify mechanisms to explain how, for whom and in what circumstances adult community crisis services work. Objectives: The objectives were to develop, test and synthesise programme theories via (1) stakeholder expertise and current evidence; (2) a context, intervention, mechanism and outcome framework; (3) consultation with experts; (4) development of pen portraits; (5) synthesis and refinement of programme theories, including mid-range theory; and (6) identification and dissemination of mechanisms needed to trigger desired context-specific crisis outcomes. Design: This study is a realist evidence synthesis, comprising (1) identification of initial programme theories; (2) prioritisation, testing and refinement of programme theories; (3) focused realist reviews of prioritised initial programme theories; and (4) synthesis to mid-range theory. Main outcome: The main outcome was to explain context, mechanisms and outcomes in adult community mental health crisis care. Data sources: Data were sourced via academic and grey literature searches, expert stakeholder group consultations and 20 individual realist interviews with experts. Review methods: A realist evidence synthesis with primary data was conducted to test and refine three initial programme theories: (1) urgent and accessible crisis care, (2) compassionate and therapeutic crisis care and (3) inter-agency working. Results: Community crisis services operate best within an inter-agency system. This requires compassionate leadership and shared values that enable staff to be supported; retain their compassion; and, in turn, facilitate compassionate interventions for people in crisis. The complex interface between agencies is best managed through greater clarity at the boundaries of services, making referral and transition seamless and timely. This would facilitate ease of access and guaranteed responses that are trusted by the communities they serve. Strengths and limitations: Strengths include the identification of mechanisms for effective inter-agency community crisis care and meaningful stakeholder consultation that grounded the theories in real-life experience. Limitations include the evidence being heavily weighted towards England and the review scope excluding full analysis of ethnic and cultural diversity. Conclusions: Multiple interpretations of crises and diverse population needs present challenges for improving the complex pathways to help in a crisis. Inter-agency working requires clear policy guidance with local commissioning. Seamless transitions between services generate trust through guaranteed responses and ease of navigation. This is best achieved where there is inter-agency affiliation that supports co-production. Compassionate leaders engender staff trust, and outcomes for people in crisis improve when staff are supported to retain their compassion. Future work: Further work might explore inter-agency models of crisis delivery, particularly in rural communities. Future work could focus on evaluating outcomes across crisis care provider agencies and include evaluation of individual, as well as service-level, outcomes. The implementation and effect of mental health triage could be explored further, including via telehealth. Barriers to access for marginalised populations warrant a specific focus in future research. Study registration: The study is registered as PROSPERO CRD42019141680. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 15. See the NIHR Journals Library website for further project information.

A mental health crisis can be traumatic for individuals and families. There are a lot of different agencies delivering crisis care. This can make getting the right help from services difficult, confusing and slow. It is not clear which services work best or who they work best for. This research explored community mental health crisis services for adults. We focused on what is working, who it is working for and in what situations it is working. Service users, carers, mental health professionals and service managers formed an 'expert stakeholder group' to guide the project by helping the researchers make sense of what we learned. We gathered information from research reports, other documents and interviews with experts (i.e. service users, carers, professionals, managers). We focused on three questions: How can services make sure that people in crisis can get the right help, quickly? What makes crisis care compassionate? Does it help if different crisis services work together? Community crisis services are most compassionate and effective when staff from different organisations share information. When leaders of crisis care help staff to work together across services, they find better ways to help people. Close working across teams gives professionals a better understanding of what other services do and makes it easier for them to give people the right help at the right time. When leaders are kind and supportive to staff, they feel better at work and provide better crisis care. It would be useful to explore if the most effective crisis services are the same ones that service users like best. We need to know more about mental health triage, inter-agency working and telehealth. Our project did not explore diversity, but this is an important topic to investigate.

Crisis care for children and young people with mental health problems: national mapping, models of delivery, sustainability and experience (CAMH-Crisis2). A study protocol.

Background: One in six five 16-year-olds have a probable mental health difficulty. Of these, almost half of older teenagers and a quarter of 11-16-year-olds report having self-harmed or attempted suicide. Currently, there is little research into mental health crisis services for young people, with little understanding of what services exist, who uses them, or what works best. Question: 'How are mental health crisis responses for children and young people up to the age of 25 sustained, experienced and integrated within their local systems of services'? Objectives:     1.    To describe National Health Service (NHS), local authority, education and third sector approaches to the implementation and organisation of crisis care for children and young people across England and Wales.    2.   To identify eight contrasting case studies in which to evaluate how crisis services have developed and are currently organised, sustained, experienced and integrated within the context of their local systems of services.    3.   To compare and contrast these services in the context of the available international evidence, drawing out and disseminating clear implications for the design and delivery of future crisis responses for children and young people and their families. Methods: A sequential mixed methods approach, underpinned by normalisation process theory will be employed. A survey will create a detailed record of how crisis responses across England and Wales are organised, implemented and used. Subsequently, eight contrasting services in relation to geographic and socioeconomic setting, populations served, and service configuration will be identified as case studies. Interviews will be conducted with children, young people and parents/carers who have used the service, as well as commissioners, managers and practitioners. Operational policies and service usage data will also be examined. Analysis of how each service is provided, experienced, implemented and sustained will be conducted both inductively and deductively, reflecting normalisation process theory constructs.

BACKGROUND: There has been a sharp increase in children and young people experiencing extreme emotional distress and/or self-harm, which is also known as 'crisis'. Services for young people in crisis are a priority in the UK but little is currently known about what crisis services exist, who uses them, or what type of service works best. AIM AND OBJECTIVES: This project aims to explore the types of mental health crisis services currently available to children and young people up to the age of 25 in England and Wales, and to examine how they are organised, perceived and integrated within other local care systems. The objectives are to: 1. Find out what NHS, local authority, education and charity sector crisis services exist for children and young people across England and Wales, to describe the services and to create a database of them. 2. Identify eight contrasting services from the database and evaluate how these services are organised, perceived and integrated within local care systems. 3. Compare and contrast these services with the available international evidence, drawing out clear implications for the design and delivery of future crisis responses for children and young people and their families. METHODS: We will use a survey to create a database of crisis response services across England and Wales. From the database we will identify eight contrasting services and we will conduct interviews with children, young people and parents/carers who have used the service as well as managers and staff. We will look at how the services work and explore how they are used and by whom. We will compare and contrast each case study and consider findings of other research studies from around the world to draw clear, actionable, lessons for the future provision of high-quality crisis services for children and young people.

Getting the pieces to fit: NHS and third sector collaboration to enhance crisis mental health service provision for young people.

BACKGROUND: The increase in demand for young people's mental health services has been met by a growth of co-located mental health service provision in the NHS and third sector. This research explores the benefits and challenges of the NHS collaborating with a charity to provide a step-down crisis mental health service for young people in Greater Manchester, and suggests how the collaboration between the NHS and third sector may be improved for future projects. METHODS: Working from a critical realist paradigm, this qualitative case study utilised thematic analysis of 9 in-depth interviews with operational stakeholders from 3 operational layers, to explore insiders' perspectives of the benefits and challenges of collaboration between the NHS and third sector in the context of the 'Safe Zones' initiative. RESULTS: Themes relating to perceived benefits of collaboration were: doing things differently, flexibility, a hybrid approach, shared expertise, and shared learning. These were counterbalanced by perceived challenges: getting the pieces to fit, obtaining a shared vision, geography, lack of referrals, and timing. The importance of effective communication (e.g. of shared vision, standard operating procedures, key performance indicators) was noted as central to addressing challenges and reaping benefits. CONCLUSIONS: NHS and third sector collaboration can yield a range of benefits, some of which can mitigate against the perceived inflexibility and restrictive nature of usual mental health service provision, thereby providing a vehicle for innovation in step-down crisis care for young people.

Serenity Integrated Mentoring and the High Intensity Network: a scheme that raises serious questions for practice and governance in UK psychiatry.

Serenity Integrated Mentoring (SIM) involved the police and mental health crisis services working in a single team, developing case management plans that allowed a seamless move from offers of therapeutic engagement (by the mental health team) to use of coercive measures (by the police) with those who persisted with frequent crisis presentations. Withdrawn after widespread criticism, the scheme raises important questions - about the practice of mental health professionals who are involved in decisions about using criminal sanctions for people presenting in crisis, about the ethical and legal status of the sharing of confidential clinical information with the police, and about the processes that professional bodies use in promoting, monitoring and responding to controversial service developments.

Establishing a business case for setting up early detection services for preventing psychosis.

Under standard care, psychotic disorders can have limited response to treatments, high rates of chronicity and disability, negative impacts on families, and wider social and economic costs. In an effort to improve early detection and care of individuals developing a psychotic illness, early intervention in psychosis services and early detection services have been set up in various countries since the 1980s. In April 2016, NHS England implemented a new 'access and waiting times' standard for early intervention in psychosis to extend the prevention of psychosis across England. Unfortunately, early intervention and early detection services are still not uniformly distributed in the UK, leaving gaps in service provision. The aim of this paper is to provide a business case model that can guide clinicians and services looking to set up or expand early detection services in their area. The paper also focuses on some existing models of care within the Pan-London Network for Psychosis Prevention teams.

Crisis service utilization following completion of a suicide safety plan for Veterans with and without affective and nonaffective psychosis.

OBJECTIVE: Psychosis is associated with increased suicide risk. Safety planning is a suicide prevention practice that is associated with decreased suicidal behavior and psychiatric hospitalizations. A common feature of safety planning is listing of crisis line numbers. The primary purpose of this study was to compare Veterans with and without psychosis who completed a safety plan in terms of their next year crisis service use, including Veterans Crisis Line (VCL) calls, and suicidal behavior. METHODS: Data were drawn from the VA San Diego's electronic medical record system for (N = 1602) safety plans from 2018 to 2021. Clinical records of crisis services and suicide attempt/death were recorded for one year after the safety plan. RESULTS: Following completion of a safety plan, Veterans with psychosis were more likely to have a next year psychiatric hospitalization (OR = 4.1), emergency department visit (OR = 2.3), and psychiatric emergency clinic visit (OR = 2.2) than those without psychosis. In contrast, there were no group differences in likelihood of calling the VCL. CONCLUSIONS: Veterans with psychosis who recently completed a safety plan do not show elevated rates of VCL use that are commensurate with increases in crisis service use. Interventions for this high-risk group may focus on understanding the motivation and ability to call the VCL as ways to enhance safety planning.

What twitter can tell us about user experiences of crisis text lines: A qualitative study.

Mental health problems are the leading cause of disability worldwide. Despite the prevalence and cost of mental illness, there are insufficient health services to meet this demand. Crisis hotlines have a number of advantages for addressing mental health challenges and reducing barriers to support. Mental health crisis services have recently expanded beyond telephone hotlines to include other communication modalities such as chat and text messaging services, largely in response to the increased use of mobile phones and text messaging for social communication. Despite the high uptake of crisis text line services (CTLs) and rising mental health problems worldwide, CTLs remain understudied. The current study aimed to address an urgent need to evaluate user experiences with text-based crisis services. This study explored user experiences of CTLs by accessing users' publicly available Twitter posts that describe personal use and experience with CTLs. Data were qualitatively analyzed using thematic analysis. Six main themes were identified from 776 tweets: (1) approval of CTLs, (2) helpful counselling, (3) invalidating or unhelpful counselling, (4) problems with how the service is delivered, (5) features of the service that facilitate accessibility, and (6) indication that the service suits multiple needs. Overall, results provide evidence for the value of text-based crisis support, as many users reported positive experiences of effective counselling that provided helpful coping skills, de-escalation, and reduction of harm. Results also identified areas for improvement, particularly ensuring more timely service delivery and effective communication of empathy. Text-based services may require targeted training to apply methods that effectively convey empathy in this medium. Moving forward, CTL services will require systematic attention in the clinical research literature to ensure their continued success and popularity among users.

Cops, Clinicians, or Both? Collaborative Approaches to Responding to Behavioral Health Emergencies.

How a community responds to behavioral health emergencies is both a public health issue and social justice issue. Individuals experiencing a behavioral health crisis often receive inadequate care in emergency departments (EDs), boarding for hours or days while waiting for treatment. Such crises also account for a quarter of police shootings and >2 million jail bookings per year. Racism and implicit bias magnify these problems for people of color. Growing support for reform provides an unprecedented opportunity for meaningful change, but solutions to this complex issue will require comprehensive systemic approaches. As communities grapple with behavioral health emergencies, the question is not just whether law enforcement should respond to behavioral health emergencies but how to reduce unnecessary law enforcement contact and, if law enforcement is responding, when, how, and with what support. This policy article reviews best practices for law enforcement crisis responses, outlines the components of a comprehensive continuum-of-crisis care model that provides alternatives to law enforcement involvement and ED use, and offers strategies for collaboration and alignment between law enforcement and clinicians toward common goals. Finally, policy considerations regarding stakeholder engagement, financing, data management, legal statutes, and health equity are presented to assist communities interested in taking steps to build these needed solutions.

Characteristics and Perceptions of Sexual and Gender Minority Youth Who Utilized a National Sexual and Gender Minority-Focused Crisis Service.

Background: Sexual and gender minority youth (SGMY) have heightened risk of suicidality; yet, we know little about their experiences when utilizing crisis services. Aims: The purpose of this study was to understand the characteristics and experiences of SGMY when in contact with SGMY-specific suicide crisis services. Method: Data were from 592 SGMY who contacted the most widely utilized national US SGMY-specific crisis services provider. Results: High rates of suicide ideation (65.2%) and attempts (31.9%) were documented, with gender minority youth endorsing higher rates of suicide attempts. Participants contacted the center by phone (57.8%) more than by online chat/text (42.2%). Participants reported discussing their sexual orientation (60.6%), gender identity (43.8%), and identity disclosure stress (56.6%) with counselors. Participants rated the crisis service as helpful. The counselors were perceived as warm, compassionate, and knowledgeable about common concerns for SGMY and they were likely to contact the crisis center again. Participants reported using chat/text over phone because it provided them with more confidentiality and privacy; however, phone contacts were rated more positively than text/chat. Limitations: The sample was predominately White and was not representative of the broader population of SGMY, limiting the generalizability of the results. Conclusion: SGMY reported positive experiences with a national SGMY-specific crisis service. The findings highlight the critical need for and utility of SGMY-specific suicide prevention crisis services.

Crisis line services: A 12-month descriptive analysis of callers, call content, and referrals.

Crisis lines are a valuable community resource that anonymously and freely serve those in acute crisis. As a result of anonymity, it has been difficult to fully characterise crisis line services. However, appraising and improving crisis line services for the communities they serve is essential, even with the additional difficulty anonymity poses. This study seeks to increase our understanding of current crisis services and utilisation via a characterisation of various aspects of a United States crisis line service centre over 12-months including features of calls (e.g. call length), callers (e.g. victimisation history), and information provided to the caller (e.g. referrals). We examine five crisis lines totalling 5,001 calls from October 2018 to September 2019. Descriptive information is provided on call volume, patterns across time, caller characteristics, victimisation types, and referrals. Although we were unable to assess prospective outcomes due to anonymity, 99.5% of callers that were asked (61.35% of all calls; n = 3,068) reported the call as helpful. This provides an important overview of crisis line services and suggests they are a valuable community health resource serving a range of callers. Given the findings of the present study, we conclude with a discussion of recommendations and implications for community crisis line centres and future research.

The Changing Landscape of Community Mental Health Care: Availability of Treatment Services in National Data, 2010-2017.

OBJECTIVE: The authors sought to describe changes in availability of crisis and substance use treatment services in U.S. mental health facilities (including outpatient and inpatient facilities) from 2010 to 2017. METHODS: Using National Mental Health Services Survey data, the authors of this descriptive study examined changes in the proportion of facilities providing crisis and substance use treatment services during the 2010-2017 period. RESULTS: Although the proportion of outpatient facilities offering treatment for substance use increased significantly during the period studied (adjusted relative risk [ARR]=1.05, 95% confidence interval [CI]=1.01-1.10), the proportion of outpatient facilities offering crisis services significantly decreased, including emergency psychiatric walk-in services (ARR=0.81, 95% CI=0.75-0.88) and crisis intervention (ARR=0.88, 95% CI=0.83-0.93). CONCLUSIONS: Mental health facilities are an integral piece of the behavioral health safety net and need to respond to changes in service needs. Findings suggest that mental health facilities have not shifted their services mix to address the ongoing suicide epidemic.