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

Emotional crisis is a universal experience that can happen to anyone at any time across the lifespan. A crisis may occur when individuals face an obstacle to an important life goal that appears insurmountable by means of their usual coping strategies. The crisis may be precipitated by one or more identifiable situational, cultural, or interpersonal stressors.

People experiencing an emotional crisis often report feeling heightened levels of fear and anxiety that affect their ability to focus, concentrate, and effectively resolve the challenges they face. Many people report that when they are in crisis, they experience tension, physical symptoms, or pain, along with associated feelings of emotional distress that may manifest as signs of depression, withdrawal, or anxiety. These feelings of distress may lead to unpleasant reactions such as grief, fright, shame, humiliation, anger, worry, frustration, sadness, anger, and helplessness. People experiencing an emotional crisis may not be able to sit still or initiate and sustain patterns of activity that they typically perform with little effort (e.g., work, leisure activities, play, or self-care). People who experience an emotional crisis benefit from having a safe, caring, and supportive environment to help them regain emotional balance.

The trending increase in the number of people who need psychiatric crisis response services has resulted in significant funding being budgeted for crisis response and its improvement (1). Peer-run respite programs, one type of resource for crisis support, are underfunded (2), possibly because of a lack of understanding of what these programs offer. Increased attention to the need for crisis services prompted us to provide in this column an overview of the essential approaches of peer-run respites that appear to make them favorable options compared with conventional psychiatric crisis response services.

Psychiatric crisis response services—the dominant model of mental health care for people in crisis in the United States—are based on a pathology model, with a primary focus on quickly reducing symptoms so that the person in crisis can resume functioning in the community. The professionals who provide psychiatric crisis response services are perceived by some as authority figures who are not inclusive of nonprofessionals and not always attuned to cultural factors and social determinants. Many service delivery settings are restrictive, which some people perceive as oppressive and unsafe. We have experienced psychiatric crisis hospitalization personally and have contributed for decades to various efforts to improve psychiatric crisis response services by consulting; providing training; and developing policies, procedures, and programs for psychiatric hospital reform efforts on the state and federal levels.

Peer-Run Respite Approaches

Peer-run respites provide a voluntary alternative to an emergency department visit or inpatient hospitalization for people experiencing a psychiatric crisis. Further, peer-run respites are staffed and operated by people with lived experience of the mental health system (3). Currently, no standardized training curriculum has been used across peer-run respites. Some staff are trained in Emotional CPR or in the Hearing Voices Network group facilitation approach; others receive solely umbrella organization training or written material on peer-run respites. Many peer-run respites train staff in the intentional peer support model, which reframes crisis as a moment of opportunity and views an individual’s trauma response as a coping effort rather than as pathology (4, 5). A growing body of research demonstrates the benefits of peer respites (6, 7).

The foundational concepts of peer-run respite approaches provide a framework for understanding them and highlight how they differ from psychiatric crisis response service approaches. In peer-run respites, the philosophy holds that every human being has three fundamental rights: the right to be seen and heard for who they are, the right to belong to a community that accepts them for who they are, and the right to have the opportunity to flourish (8). Peer-run respite staff maintain an unwavering perspective of believing completely in the full potential of every person, which means seeing beyond the profound effects of various forms of oppression, including but not limited to racism, sexism, classism, and mental health oppression. Mental health oppression requires conformity to look “normal,” which means not showing one’s struggle and hiding one’s real self for fear of being labeled deviant. The impact of all forms of oppression typically means that people see through a lens tinted with past hurt, trauma, misinformation, and humiliation. When people understand that they are not being seen for who they are (because of the impact of oppression) and for their fullest future potential, their ability to fully be themselves and create the life they want is diminished.

These concepts invite mental health professionals to rethink their perceptions of and approaches to supporting individuals experiencing an emotional crisis. Rather than pathologizing behavior, peer-run respite staff use curious inquiry to explore the intelligence—that is, the logic and coping strategies—that is working for the guest. They may examine what purpose the guest’s behavior is serving or supporting. Thus, staff engage with the guest to explore the intelligence being used to navigate the crisis. For example, it may be that the guest found retraction, numbness, or dissociation to be effective in managing the situation and their emotions, given the circumstances. By respecting coping mechanisms as intelligence, staff can lead the guest through a gentle exploration of the layers of distancing (or numbness or retraction), giving the guest the space and the support necessary to feel their emotions. This approach allows more understanding and wisdom to flow and brings relief to the guest, easing their need to compartmentalize and numb their body, mind, or emotions. Of note, the trauma leaves people feeling numb, which highlights the importance of being mindful that interactions be respectful and compassionate.

Next, we outline differences between the psychiatric crisis response service and peer-run respite approaches to crisis. (For additional information, see the online supplement to this column.)

How Emotional Crisis Is Understood

Psychiatric crisis response service providers focus primarily on an individual’s behaviors or symptoms, often without considering underlying stressors, risk factors, and social inequities. In peer-run respite programs, by contrast, emotional crisis is defined as a universal experience that happens when circumstances exceed a person’s current capacity to effectively cope with them, especially when appropriate resources and the adaptations needed for the person in distress to thrive are not accessible. The way a person responds to a crisis may be viewed in psychiatric crisis response services as pathological but in peer-run respites as a valid and meaningful coping mechanism that is protecting the person from trauma or challenging circumstances that stem from a range of social inequities.

Goal of Crisis Response

The goal of psychiatric crisis response services is primarily to reduce or eliminate symptoms and modify behavior to rapidly stabilize the person in crisis, usually with psychopharmaceuticals and professional supports for managing a so-called mental illness. The goal of peer-run respites is to create a mutually respectful space where compassion is offered, individual choice is honored, and the guest can realize they are not alone. By providing a safe environment, peer-run respites allow guests to feel supported, find meaning in the crisis experience, regain emotional balance, reclaim their power, and determine their next steps.

Self-Determination

Psychiatric crisis response service providers tell the person in crisis what they think is best for the person and expect the person’s compliance with interventions and programs that may or may not meet the person’s genuine emotional needs or align with the person’s values. In contrast, peer-run respite staff help each guest to consider available options and to identify and practice new skills to meet their needs, care for their body, and return to a life that aligns with their values.

Power Dynamics

In psychiatric crisis response services, decisions are guided by professionals, because the person in crisis is believed to be unfit to manage their life. This directive approach may be experienced by the person in crisis as a violation, and, in response, the person may withdraw from treatment; grudgingly comply with it; or act out in anger because they are not being seen, heard, or understood. The peer-run respite approach embraces the philosophy of “power with” rather than “power over.” Decisions are guided by guests in crisis, whose knowledge of themselves and their situation is honored. By listening, exploring guests’ experiences and perspectives, and supporting them in thinking and feeling their way through the crisis, the peer-run respite staff encourage guests to take charge of their own lives, even when that means venturing into unknown territory and tolerating uncertainty.

Being With Versus Doing To

Psychiatric crisis response service providers evaluate the person in crisis with the goal of identifying ways of minimizing or eliminating what they perceive to be problematic behaviors, feelings, or ideas, primarily by using psychiatric drugs or other types of confinement. A peer-run respite serves as a safe space in which peer-run respite staff can “be with” the guest in crisis—listening to the guest, exploring together the literal or symbolic meaning of the crisis, and supporting the guest as they move toward meeting their expressed needs and desires. Peer-run respite staff are acutely aware of the impact of their own words and actions and communicate in ways that are authentically validating, inviting openness with regard to reflecting on inner experiences and allowing the guest to move through the crisis while also considering their hopes and intentions for the future.

How Trauma Is Viewed

Psychiatric crisis response service providers view behaviors and emotions as the outcomes of a chemical imbalance, although this view is shifting with a growing awareness of the role of trauma in emotional crisis (9). Peer-run respite staff view trauma as a central factor contributing to most life-interrupting crises. Trauma may be individual, intergenerational, or communal. Racism, sexism, poverty, and other forms of systemic oppression are sources of trauma that affect people’s lives and are often perpetuated by the health care, education, political, and criminal legal systems. In peer-run respites, guests who have experienced trauma are supported so that they have the security and space to trust their wisdom, come to their own understanding of their experience, and determine their next steps.

Trauma-Informed Approaches and Environments

Many challenges are inherent to implementing trauma-informed approaches in psychiatric crisis response services. Sometimes, people are committed to psychiatric crisis response services against their will. Inpatient environments are generally sterile and structured around safety and risk management. Strategies to ensure physical safety sometimes lack emotional safety. Psychiatric crisis response sometimes results in violent intervention, including lethal force, which affects not only the person in crisis but also witnesses, families, and the entire community.

Peer-run respites use trauma-informed approaches and environments. Guests seek support on a voluntary basis. Program environments are designed with consideration of spatial elements that provide physical, environmental, and emotional safety in a homelike setting. In a qualitative study of former guests of peer-run respites, many respondents cited the cleanliness, safety, privacy, and homelike setting of the respite—with its noninstitutional veneer and the availability of a kitchen, living room, and bathroom and many standard household appliances—as contributing to their relaxation and recovery (2). Peer-run respite staff are trained and supported to be sensitive and effective in their ability to communicate with other people. Practicing and refining attunement (i.e., a feeling of spaciousness and presence) deepen the ability of peer staff and the guest to be aware of each other’s feelings, making it possible for all parties to respect each person’s emotions and helping the guest feel cared for and listened to.

Relationality

Psychiatric crisis response service providers are trained to maintain a professional distance (e.g., by setting boundaries) from individuals in crisis. Peer-run respite staff are trained and supported to practice attunement (as described above), which enhances their capacity to be more sensitive and effective in interacting, communicating, and connecting with guests and other staff members. The attunement process, which to us represents an essential aspect of the emotional healing process, helps people let go of any feelings or thoughts that interfere with being present and listen to the others with whom they are cocreating a safe space that invites deeper mutual learning. This process provides the opportunity for a guest and staff to gently explore memories and emotions that may come up if the guest is interested in doing so. The safety of the relationship provides an opportunity for the guest to explore what meaning the crisis and the guest’s emotions may hold and thus to digest and integrate the experience. This relationship also enhances the guest’s sense of empowerment and willingness to be creative in exploring new pathways for living. Furthermore, forming a bond with the staff allows the guest to tap into inner resources for finding calmness and feeling connected. Many people find that the ongoing practice of this process leads to feeling more grounded in their body and deepens their relationships with themselves and other people. This process empowers people to further explore their relationships and practice responding in supportive ways that are aligned with their deepest intentions and values. An individual’s highest potential is recognized—not only for healing but also for cocreating the relationships and the collective spaces envisioned. The authentic quality of relationships is critical to cocreating transformative, mutually respectful spaces.

Conclusions

Psychiatric crisis response service providers should consider adopting some of the peer-run respite approaches outlined in this column to prevent escalation of emotional distress for people in crisis and to promote emotional health. Creating safe and supportive relationships strengthens a person’s tolerance for uncertainty, and this capacity helps people reclaim their power, recognize their potential, and cocreate relationships and collective spaces for healing. Research on peer-run respites to date is promising; however, additional qualitative and quantitative data need to be gathered from current and former guests. We invite researchers to examine in more detail how the physical environment of peer-run respites contributes to healing. We welcome the support of researchers and policy makers for coproduction of research and program evaluation projects that explore whether and how these peer-run respite approaches are helpful and lead to positive outcomes for people experiencing an emotional crisis.