Alternatives to mental health crisis support: are we asking the right questions?

The front of a hospital. The text Accident & Emergency is visible in red, above light green doors and the wording A & E in big white lettering against red.

There is a call for information currently being circulated inviting submissions to help identify models which are alternatives to standard inpatient crisis care in mental health in the UK.

For those of us who have sought alternatives for ourselves or loved ones, or those of us who work in this area, there will likely be no surprises on this list when it’s compiled. We know what they are, because there are so few.

I’ve seen and taken part in many such calls, most notably during the Independent Review of the Mental Health Act in 2018. I was easily able to roll off the paltry list (it has barely changed in five years). The responses which followed from commissioners and service providers were similar: but these models are not scaled. But they are not adequately evidenced. But these only cater to a very narrow group of people. But these are not for people who are in real crisis. Therefore they cannot replace inpatient services.

It seems to me that if we want a different response, we need to move beyond a scoping exercise, and we need to be asking ourselves different questions around the provision of alternative support for people experiencing a mental health crisis.

The current starting point is too narrow, because the current provision is impoverished. By focusing on what currently exists in the UK, we’re not asking what is missing. Instead of asking for evidence on what currently works, we might be asking why calls for evidence in this field are likely to yield unsatisfactory data which risk reinforcing the status quo.

What is needed instead is an envisioning exercise, based on asking people what they might need, with the resources to pilot new approaches.

Informal networks of support

What research is not adequately capturing is how most ‘alternatives’ to mental health crisis care are informal. It’s family members, friends and communities stepping in and offering time, money, care packages, dog sitting, childcare, pharmacy runs, mutual aid, late night phone calls, and sofas to loved ones in crisis. These are the acts and these are the networks which are holding so many people through the darkness.

Additionally, the prevailing framing of crisis support doesn’t see people who are invisibilised by the current systems: people who cannot access crisis support because of their immigration status, people who are not safe to access services because of the institutional harm caused by them, people who are denied access to services because of their diagnosis being weaponised. Many of these people are also not served by the voluntary sector alternatives in place, as gatekeeping and harm can span multiple settings.

Capturing these informal networks of support would require different tools, and would invite us to step outside of traditional calls for evidence and data. The key question here is not how we might reproduce or scale informal crisis support. Instead, we might ask ourselves why it’s so prevalent, where it fits within other crisis support, whether and how it can be better resourced, and where it is not enough.

Clearly not everyone has friends or family who can step in. Even if you are able to be there for someone, it may be that in that moment you yourself are too frayed or exhausted to do so. This is particularly salient for communities who are harmed or excluded by services, and who have to rely on themselves. So while family and community support will always be a feature of supporting people in crisis, and while some people will always choose this over voluntary or statutory services, it cannot be the only option. At the moment, that is the case for too many people, because there is no safety net beyond that.

Voluntary sector support

The voluntary sector support which exists for people experiencing a mental health crisis in the UK is often temporary, subject to gatekeeping, and patchy in its provision. The services themselves are often poorly funded and precarious, delivered by volunteers, trainee counsellors or peer support workers. It is not that the models used – befriending, counselling, peer support – are inappropriate: they can be powerful and valuable ways of connecting to people in crisis. It’s that too often the choice of model is dictated by cost instead of vision. For example, peer support is often commissioned because it is cheaper, instead of being commissioned because it is the best fit, and then resourced accordingly.

Many have also argued that the failings of inpatient crisis support are being papered over by voluntary sector provision, with inpatients being directed to the Samaritans and other crisis helplines by mental health services if they would like to talk. The Samaritans has a place. Its place is not to cover the inadequacies and failings of mental health services.  

Within this wider context, any call for evidence around the efficacy and impact of voluntary sector crisis alternatives will encounter numerous hurdles. When we are comparing alternatives to inpatient crisis support, we are not comparing like with like in terms of funding or scale.

Maytree, a respite house in London offering a 4 night stay residential stay for people in suicidal crisis, had an annual income of £772,413 in 2021. Due to the constraints of the pandemic, it supported 32 people through a residential stay in 2020/21, compared to 153 in 2018/19. These numbers represent people. But, speaking from a policy perspective, the numbers here, and for other community alternatives, are unlikely to add up to a convincing case. 

When policy makers do latch on to something, their focus is too often on reproducibility: how can we take this thing that seems to work quite well, and scale it across the country? It bypasses the very strength of these alternative approaches: that where they work, it’s because they spring from the needs of their communities, it’s because they are small and personalised, it’s because they’re not for everyone. 

The other feature which makes voluntary sector alternatives difficult to compare to inpatient settings is that they have exclusions of their own. Charitable funding restrictions can stipulate that support cannot act as a replacement to statutory services. As such, one of Maytree’s rules is that you can only have one stay. Many community crisis support services will not accept people whose experiences fall under the umbrella of psychosis. These restrictions and exclusions can serve to uphold the status quo argument that yes, there is a role for alternatives, but they are not for people who are really unwell.

What is needed

We absolutely need more Maytrees – and there are welcome moves to open a new house in Manchester – and we need more Drayton Parks and more survivor-led crisis houses. But we also need alternatives which don’t yet exist in this country, because the starting point is always to look at what currently exists, rather than ask ourselves instead what is missing, and what is needed.

This might include:

  • Starting with the person to find out what they need.
  • Material and practical support for people, which integrates health and social care, to ensure that staying at home when in crisis is a real option. This might include emergency childcare and carer support, pet sitting/caring, or practical support with shopping and food.
  • Flexible drop-in 24-hour community crisis support which offers befriending, counselling and practical support. 
  • An array of short-term residential crisis support available across the country, accessible to people with different needs and lives, offering different models of support and length of stay, both referral and self-referral.
  • Support which is integrated into people’s lives outside of the crisis.

Beyond taking into account the material conditions in which a crisis can arise, for example precarity, debt and homelessness, and addressing these through policy and other interventions, this would also involve:

  • Widening our definition of crisis. Looking at crisis support through a narrow lens means missing all the intermediate steps at which a person might need support. Current definitions can also contribute to neglect, where people are deemed to not meet the threshold for crisis and therefore cannot access support.
  • Moving away from a one-size-fits-all model.
  • Moving away from scaling existing services and interventions.
  • Piloting new, more radical models of crisis care and support.
  • Investing in grassroots community work.
  • Looking to other countries for alternatives.
  • Connecting with, learning from and resourcing people and communities here in the UK who might not describe themselves as doing mental health work, and are not “mental health first”, but have experience and wisdom in supporting people in crisis.