Peer Respites Hold Promise for Reducing the System’s Reliance on Institutional Treatment

Bevin Croft
17
339

This month, two of our nation’s most respected publications, the New York Times and the Journal of the American Medical Association, published opinion pieces calling for a return to institutional settings for people diagnosed with serious mental illness. Both are poorly reasoned, casually dismiss the rights and preferences of an entire subset of the human population, and play on public fears about a link between violence and mental illness. It seems these writings may have made it to the pages of such hallowed publications because they are part of a perfect storm of political forces that include Rep. Tim Murphy’s efforts to expand assisted outpatient treatment (AOT) and dismantle the Substance Abuse and Mental Health Services Administration (SAMHSA), a damning report from the Government Accountability Office (GAO) criticizing SAMHSA and other federal agencies, and a growing concern that prisons and jails play an increasingly de facto role in the behavioral health service system. There’s no doubt that the system needs improvements, but calls for institutional treatment ignore decades of research documenting the effectiveness of community-based services and supports that, if adequately funded and properly implemented, enable people diagnosed with serious mental health conditions to live rich lives and contribute to society in meaningful ways.

As my colleague Laysha Ostrow and I describe in an Open Forum, published online in Psychiatric Services this month, peer respites are short-term residential programs that offer trauma-informed peer-to-peer support for individuals experiencing extreme states. Peer respites are designed for individuals who may be heading toward a mental health crisis that might otherwise lead to an inpatient hospital stay. These programs are largely unstructured and explicitly non-clinical, focusing instead on creating an environment for guests and staff to foster mutual healing relationships. Peer respites create space for guests to move through extreme states in a manner of their choosing. Many use Intentional Peer Support, a trauma-informed practice that focuses on mutual learning relationships and social change, as an organizing framework. Currently, there are 16 peer respites operating in the United States, and four more are in the planning stages. Although a fair amount of research has documented the effectiveness of peer support and residential crisis alternatives, relatively little has examined peer respites in particular. One 2008 study of a peer respite documented higher satisfaction, improved symptoms and social functioning, and higher self-esteem for peer respite users compared with individuals committed to an inpatient hospital.

In the same issue of Psychiatric Services, my colleague Nilufer Isvan and I published some early findings of an evaluation of the Second Story program, a peer respite in Santa Cruz, California. Second Story is one of the first peer respites in the country; it opened in May 2011. The program is funded through a combination of county behavioral health department funds and a grant from the Substance Abuse and Mental Health Services Administration. The SAMHSA grant is slated to end this year, and as the county determines its funding priorities for the coming years, Second Story’s future remains uncertain.

We included 139 individuals who used the peer respite between May 2011 and June 2013 in the analysis. Instead of randomizing participants in the study to create an “intervention group” and a “comparison group”, we used a statistical method called propensity score matching (the details of this are described in the article) to establish a comparison group of 139 Santa Cruz County residents who did not use the program. We compared the two groups (respite users and those who had not used the respite) to ensure they had similar clinical, demographic, and behavioral health service use characteristics. This allows us to reasonably assume that the two groups are similar enough to draw some conclusions about the effect of the program on service utilization.

First, we examined the likelihood of using inpatient or emergency services after the respite start date. Next, we looked at total hours of inpatient and emergency service use for the 98 individuals in either group who used any of those services. In all of our analyses, we took individuals’ clinical, demographic, and behavioral health service use histories into account.

We found that the respite guests had a 70% lower probability of using inpatient or emergency services compared to the group of similar non-respite users. For the individuals who used any inpatient or emergency services during the study period, a longer stay in respite was associated with fewer hours of inpatient and emergency service use.

A closer look at the results suggests a complex relationship between respite and inpatient and emergency service use. Although respite guests were on average less likely than the non-respite group to use inpatient or emergency services, each additional day spent at Second Story increased this likelihood. That is to say, respite guests with longer stays at Second Story had a higher likelihood of using inpatient or emergency services than guests with shorter stays. Similarly, the length of respite stay had diminishing returns in terms of reduced hours of inpatient and emergency service use, with negligible decreases predicted beyond 14 days of respite.

In the article, we discuss some possible reasons behind these findings. Because these analyses relied solely on county administrative data, it is very likely that factors we couldn’t measure had an impact on the relationship between peer respite and inpatient and emergency service use. Although we had rough measures of housing status, for example, we know from our qualitative work that many respite guests experience instability in housing, and that this instability is an important factor in decisions to visit both peer respites and emergency rooms.

Although the findings had some important nuances, they point to a high degree of promise for peer respites to decrease the behavioral health system’s reliance on coercive and isolating interventions like inpatient hospitalizations.

In the coming year, we plan to repeat the analyses described above with four years of data rather than two. Using a larger sample size, we hope to better understand the relationship between peer respites and inpatient and emergency service use. Also, these results reflect only one part of the Second Story program evaluation. We’ve been working with a group of peers who have been meeting with Second Story guests these past four years to ask about their experience with the program and their lives in general to understand how—if at all—the program helps people to achieve a higher quality of life. To explore these questions, we used both surveys and open-ended interviews to capture the range of possible experiences with the program. If you’re interested in learning more about this kind of research, you can find a toolkit on evaluating peer respites written by Laysha and myself here.

We hope the results of this and other future research will help to answer some of the important questions we uncovered in this first analysis and paint a richer picture of how peer respites can improve people’s lives and contribute to a behavioral health system that is more humane and less traumatizing. This research might help to counter the push to bring back asylums and other such misguided, ahistorical, unscientific calls for reform.

17 COMMENTS

  1. Thank you for working on an alternative to our current inhumane, defamatory and traumatizing psychiatric system. And for publishing your findings. I do so hope those pushing for the institutionalization of innocent patients who don’t react well to the psychiatric drugs does not become a reality.

  2. Thank you so much for your work. It is scary how services in direction of coercive treatment seems to be expanding despite recent findings of the adverse effects of long term use of psychotropic medication.

    How do you suggest people support your work?

  3. Thank you so much for this article. I am in strong support of peer respite services, and the primacy of persons with lived experiences in any healing process. We need to protect against the “institutionalization” of peer based support, as I cannot trust our system to integrate this essential and compassionate resource without totally corrupting it.

    I am deeply concerned about the push toward increasing coercive treatment and institutionalization. That’s a bit of an understatement – this push is terrifying with the potential for lasting severe harm. It doubles down on everything that hasn’t worked, will never work and indeed can’t work and is driven by a desire to simply be “rid” of the nuisance of those “other people” as well as predatory fear-mongering about dangers and risks to the community.

    Pair that with recent reporting on the renewed increase in money pharmaceuticals are putting into psychiatric drug research (after a period in which they appeared to be giving up on that effort in the absence of clear biomarkers) and it feels as though we are heading toward an extremely dark time. Now more than ever before we must consistently stand for what is accurate, reasoned, and truly evidence-informed – including pointing out the limits of what anyone (most especially those claiming institutional “authority”) actually know about the causes, course and best “treatment” for persons who experience more extreme emotional states.

    The role of peers – persons from all walks of life who self-identify with lived experiences of both extreme states as well as experiences with the misuses and abuses of our “mental health” system – has never been more critical. Nothing has been more powerful in my own efforts to be a compassionate partner in a fellow human’s journey than my willingness to honestly share my own history of struggle. Almost nothing is more important. Thank you again.

    • I see this as a part of bigger problem in society: with the class war raging and rich getting richer of our backs there need to be mechanisms to keep potential opponents of the system in check. Creating the fear of “other” (who happens to be the powerless one – blacks, Muslims, “mentally ill” etc.) puts the blame on someone else and allows one disenfranchised sector of population to vent their rage and fear on another without harming the real perpetrators. We’ve seen this movie before and it does not end well…

  4. I must say, I shake my head every time I read the term “behavioral health”… there’s no such thing. Behavior is not an issue of “health”, or of medicine. Nobodies behavior can be “healthy” or “unhealthy”, but to begin rationalizing behavior as “health” puts it in the domain of medicine, where the goal can only be to eventually replace everything from police and prisons with doctors and psychiatric goon squads.

    Should medicine become the future of policing and corrections? When the “treatments” are brain damaging drugs, the professions have no science at all and the financial costs are astronomical… I cant imagine the sort of irrational thinking someone would need to think medicine is a good place to turn to deal with “behavioral” issues.

    • I agree, the term “behavioral health” sets my teeth on edge! Behavior doesn’t have health! People have health! It goes to show that the current paradigm is intent on reducing us to mechanical devices so that the only thing that matters or even really exists is our “behavior.” BF Skinner would be proud.

      —- Steve

  5. I appreciate this article and peer respites!

    I wonder if the effects, both physically and psychologically of being in the system, medicated, given labels etc don’t create very complicated pictures for the people who may choose to use peer respites…I wonder if we should add services to the respite, perhaps a medically supervised detox unit for people who are reducing meds. , including PRN meds, Open Dialogue and trauma informed professional and peer support to give people all that they need to move through their crises? I am in no way advocating for forced treatment or coercive services…I wonder if more people could benefit from a wider array of non-hospital alternatives…14 days of peer support is not enough time for those guests who are in recovery from decades of unaddressed trauma, meds, forced hospitalizations and labels…

    Thank you for your work and for sharing it with us…

  6. Hi Bevin
    Thanks for a great article, peer support and peer respite are my passion. We run a peer support respite house here in Nelson, New Zealand, called Kotuku. Kotuku is the Maori name for a white heron which the Maori consider to be a symbol of things both beautiful and rare and for Maori to compare a visitor to a Kotuku is viewed as a compliment of the highest order. It opened in 2007 and was the first peer led respite in the country and although now there are peer support respite facilities throughout the country our service remains one of the few that are truly “Peer Led”.

    Bevin I couldn’t open the link to your toolkit on evaluating peer respite and I would really like to see this to help with our work.

    Hi Andrew, I totally agree with your comment below.

    “We need to protect against the “institutionalization” of peer based support, as I cannot trust our system to integrate this essential and compassionate resource without totally corrupting it.”

    We base our work on the Intentional Peer Support Model and it is vitally important for the service to stay true to this model, therefore not allowing corruption from mental health services. It is also vitally important that we remain totally peer led. I have seen other “Peer respite” being managed by non peer staff and basically become the pawns of the local mental health team to, which is just awful. I was working in a clinical team in the ajoining town when Kotuku opened and the BS I heard from clinicians that I worked with at the time was horrendous “There’s no way people with mental illness could do this work” was basically the flavour of the conversation, the team was so anti it they used there “peer respite” money to open a respite house managed by another NGO who has supported accommodation, with a couple of peer support workers on the staff. I have to say having seen both services running Kotuku is a much more healing environment. (I’ve got my fingers toes and everything else crossed that we will steal their contract and take over that house as it is contracted to the same district health board that we are.)

    We are also in the process (unfortunately it’s taking too much time) of opening a peer run acute alternative to hospital. When researching this I discovered that in the USA you do not make this distinction. However it will be a total alternative and have “Peer” clinical staff. (unfortunately they will have to nurses due to administering medication.) My goal would be to make it a medication optional place but due to having to work with the system I am not mentioning that one until funding is secured and we have opened.
    There is one such place in NZ and here is the link.
    http://connectsr.org.nz/piri-pono/

    I would love to see that eventually there are no mental health unit/hospitals but many peer led houses offering true places of healing. That is one of my visions for mental health, the other is that it is peers who run all mental health services.

    • I am a peer-clinician and agree that it is critically important for peer staff not to be controlled or disrespected by clinical staff; power must be shared always and people being served should lead the way…my hope is to have something like you describe…a range of services and supports for people so they would never end up in an ER or a traditional psych hospital..but have alternative, humanistic, peer-professional support in whatever setting they want and need…