Have you ever noticed the way we behavioral health folks respond when something doesn't work the way we had hoped? One of our most common responses is to do more of it, to try harder, to test it longer. When it still doesn't work, we all too often conclude that this is the best we can expect and settle for mediocrity.
This almost happened to META Services, Inc. (a recovery services organization in Phoenix) when it was transforming its crisis services. META's first approach to upgrading the program's quality was to add space and do more of what staff already were doing. This would have improved the service, but was it the right service to begin with?
During a lucid moment, the management team remembered that phrase about “doing the right thing versus doing the thing right.” Was doing more of the same program just doing the thing right, rather than doing the right thing? Was there a better approach?
Creating a Living Room
Since the organization's overall plan was to develop services that have a strong recovery focus, META had set a goal of eliminating restraint and seclusion practices and was close to achieving it. Adding peer staff (employees having experienced behavioral health crises themselves) to the crisis team had been a key element in reaching this goal. Peer staff had modeled a meaningful way of being with people that was very effective: They were less distracted by people's problems and more able to connect with the person instead of the problem. Peer staff had successfully engaged people who were distant, deescalated those who were agitated, and inspired those who had learned to be helpless and hopeless.
META, therefore, decided to turn additional space over to peer staff and have them offer an alternative to the traditional crisis center approach, thinking that this could be a path to doing the right thing and doing the thing right.
Within a few weeks the concept took hold and gained traction. The new peer-operated crisis alternative was aptly named the Living Room, and it occupied a space adjacent to the regular crisis program. More peers were hired to staff the Living Room around-the-clock.
Peer employees had received 70 hours of peer employment training,1 plus another 35 hours of orientation before they joined META's workforce. A few more hours of training were added in areas unique to a crisis setting, such as maintaining peer interventions' integrity in a crisis setting (Staying aligned with peer principles could be challenging given the work's emergency nature). Peer staffers' most effective contributions come from a position of mutuality, being able to share their own recovery experiences and offering hope.
To create a less clinical and more comfortable and natural environment, META furnished the Living Room with couches and a TV, a refrigerator with snacks, and small individual rooms around the perimeter with futons for comfortable sleeping (if desired). Peer employees could meet privately with people and/or complete paperwork in a couple small office areas.
Most of the medical staff in the adjacent crisis program initially were less than enthusiastic about the Living Room, and their concerns mostly were regarding safety. They were afraid peer employees' own recovery would be at risk if they were subjected to the daily stress and risks of a crisis environment. The medical staff were concerned about their own safety, too, arguing that if peer employees could not handle the risk factors, everyone would be at increased risk for physical injury from people who are out of control. The medical staff also questioned if peer employees could carry the workload.
Peer employees responded to the medical staff's concerns by expressing enthusiasm for the opportunity to contribute to the recovery of people in crisis. Peer employees explained that their competencies derived from both personal crisis experiences and from training. Regarding safety, peer employees reminded medical staff that they had been in the crisis clinic several times and had not been frightened.
The first few days of the Living Room's operation were awkward because of these conflicting attitudes, but as relationships between the medical staff and the peer staff developed, the situation improved. The medical staff learned to use and appreciate the peer staff's skills and knowledge. For example, if medical staff were working with someone with a substance use issue, they would have him talk to a peer staff member who had recovered from substance use to explain the process and offer hope.
At one point the peer staff's leader asked the medical director why the medical staff's attitude had shifted, with referrals to the Living Room skyrocketing. The medical director responded, “I can't speak for anyone else, but I've been sending people over here because you guys write better discharge plans than anyone else here.”
A year later another Living Room opened at META's other crisis facility. Unlike the first Living Room, which was in a locked central space that allowed stays for no more than 24 hours, the new Living Room was unlocked and had eight beds to permit stays for up to five days. Medical staff at the second facility had some of the same initial concerns, but these were mitigated by the first Living Room's strong support from the medical staff. Concerns about the second Living Room being unlocked subsided after a few months of successful operation.
After the second Living Room's first month of operation, the number of people being sent from the second META site to hospitalization dropped from 16 to 6. This reduction was so dramatic that META assumed it was an error, but after the second and third months referrals to hospitalization dropped to 5.
What was the peer staff doing to make such a big difference? Peer staff tended to focus on the person, not the problem. They weren't prone to “pathologizing.” Peer staff were more likely to say, “Yeah, I know what you mean. I've been there myself. I'm recovering and so can you. What's worked for you in the past? What can we do to help?” On the other hand, crisis staff trained in traditional assessment and evaluation were more likely to focus exclusively on the person's problems, which appeared to overwhelm the person and render him less capable of identifying workable solutions. Of course, it's important to understand the extent of the person's problems that caused them to seek services from the crisis clinic. Clinical staff is trained to assess safety issues related to the presenting problems. Sometimes, however, this is done to the exclusion of looking at a person's resourcefulness and strengths, and this is the important focus that the peers naturally brought to the team.
Encouraged by their experiences with the Living Rooms, in the fall of 2005 META organized three focus groups of people who had used crisis services and/or psychiatric hospitals. Attendees were asked, “If you could design an ideal program that you would most want to use the next time you have a need for crisis or hospitalization services, what would it look like?” In summary, the focus groups described a place:
where they can receive immediate help with life crises;
that has a holistic approach instead of a singular focus on illness and medication;
that is comfortable, homelike, and less clinical;
that is accessible and with regular transportation (people want to be picked up by the facility, not the police);
where family and friends can visit;
that is nice enough that they aren't embarrassed to be there;
where they feel safe (no involuntary aspects);
where they can make a sandwich if they want to, or make one for someone else; and
that has a rigorous recovery program to quickly get their lives back on track.
If you have an opportunity to develop a crisis alternative program, we hope you consider the lessons from the Living Room project and the focus groups' advice. During a crisis, people often are open to listening to themselves and others about how to move ahead with their lives. If they are in a setting where they don't feel safe, don't feel like they have any choices in what happens to them, and don't have an opportunity to take personal responsibility for their plans, a chance for recovery can be lost again.Lori Ashcraft, PhD, directs the Recovery Education Center at META Services, Inc., in Phoenix.
William A. Anthony, PhD, is Director of the Center for Psychiatric Rehabilitation at Boston University.
- Hutchinson DS, Anthony WA, Ashcraft L, et al. The personal and vocational impact of training and employing people with psychiatric disabilities as providers. Psychiatr Rehabil J 2006; 29:205-13.