The provision of comprehensive crisis intervention by a charitable organisation: findings from a realist evaluation

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  • 1 University of Otago (Wellington), , New Zealand
  • | 2 Te Herenga Waka – Victoria University of Wellington, , New Zealand
  • | 3 University of Otago (Wellington), , New Zealand
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Public and academic discussion about the needs of people experiencing suicidality and psychological distress is focused on the improvement and expansion of clinical services. The potential of non-clinical, voluntary organisations providing comprehensive support is overlooked. This article reports findings from a realist evaluation of a charitable organisation in New Zealand that provides crisis respite. Two phases of data collection and analysis enabled the development of a programme theory explaining how respite supports people experiencing suicidality and distress. Data from interviews, participant observation, document analysis and a focus group were examined using thematic analysis. The study identified key outcomes of this respite service, along with the contextual factors and mechanisms that explain how these outcomes were generated. This study demonstrates the effectiveness of respite and the benefits of crisis services operating as charitable organisations. The apparent advantages of volunteerism are discussed in the context of a trend towards professionalisation in crisis intervention.

Abstract

Public and academic discussion about the needs of people experiencing suicidality and psychological distress is focused on the improvement and expansion of clinical services. The potential of non-clinical, voluntary organisations providing comprehensive support is overlooked. This article reports findings from a realist evaluation of a charitable organisation in New Zealand that provides crisis respite. Two phases of data collection and analysis enabled the development of a programme theory explaining how respite supports people experiencing suicidality and distress. Data from interviews, participant observation, document analysis and a focus group were examined using thematic analysis. The study identified key outcomes of this respite service, along with the contextual factors and mechanisms that explain how these outcomes were generated. This study demonstrates the effectiveness of respite and the benefits of crisis services operating as charitable organisations. The apparent advantages of volunteerism are discussed in the context of a trend towards professionalisation in crisis intervention.

Introduction

The prevalence of suicidality and psychological distress continues to be an issue of international concern (Chiu et al, 2018; Sheppard et al, 2018; Naghavi, 2019; Turecki et al, 2019). Arguably reflecting the medicalisation of suicidality and distress, discussion of how best to respond to the issue often focuses on the expansion and improvement of clinical mental health services (Bruffaerts et al, 2011; Elliott, 2017; Klevan et al, 2017; Singh et al, 2019). Meanwhile, the role of non-clinical, third sector organisations in providing comprehensive support to people experiencing suicidality and distress remains largely overlooked.

Although some people experiencing suicidal thoughts may simultaneously experience mental illness and require clinical services, often such services are accessed simply due to the lack of comprehensive alternatives (Clarke et al, 2007; Taylor et al, 2009; Boscarato et al, 2014). Non-clinical crisis services do exist in many countries – the most common example of this being telephone hotlines (James, 2016). However, there is a distinct absence of non-clinical crisis services that provide more comprehensive support. For people in crisis who require more support than can be provided by a telephone conversation, yet who do not require clinical intervention, the options are limited.

Respite is one form of support that can be provided without clinical staff and can, in some circumstances, serve as an alternative to clinical services. As a non-clinical yet comprehensive service, respite has the potential to strengthen the spectrum of crisis responses. The use of respite specifically as a crisis intervention for people experiencing suicidal thoughts is relatively uncommon and not well researched. Although the lack of research presumably relates to the scarcity of such services, it can also be understood within the broader context of a lack of evaluative studies in the field of suicide prevention (Coppersmith et al, 2017).

This article presents key findings from a realist evaluation of a crisis respite facility called the Taranaki Retreat. The Taranaki Retreat opened in March 2017 and is located in a rural area just outside the city of New Plymouth (population 58,300), in New Zealand. It is a charitable organisation funded by donations and staffed largely by non-professional volunteers, with a small number of paid staff. It accepts self-referrals from people experiencing suicidality and acute distress, regardless of mental health diagnoses. Standard respite stays are either five or 10 days long and are provided at no cost to service users (who are referred to as guests). Individual guests as well as family groups can be accommodated, with four guest bedrooms available. Guests under the age of 15 years must be accompanied by a guardian.

In addition to its primary function of offering respite, the Retreat matches each guest with a support worker who provides practical and emotional support. A variety of optional activities, from art and crafts, to gardening and pilates, are made available for guests during their stay. Follow-up contact and support are also often provided for a limited period after a guest has left. Where necessary, guests are connected to other support services in the community for longer-term assistance. The retreat does not offer respite for people experiencing acute mental illness (such as an episode of psychosis or mania), nor those whose primary presenting issue is drug or alcohol dependence.

Broadly, this study asked: How does respite function to support people experiencing suicidality and distress? As a realist evaluation, it specifically asked: What are the key outcomes for service users of the Taranaki Retreat? What are the underlying mechanisms that generate these outcomes? And finally: What are the key contextual factors in which these mechanisms operate? By answering these research questions and developing programme theory at a middle range of abstraction, this study aimed to move beyond vague notions about the helpfulness of respite, to a richer explanation of how respite functions in the context of suicide prevention. The purpose of developing this explanation is to support the improvement of crisis intervention services – in particular, non-clinical crisis services.

After describing the realist evaluation design and the research methods, we present the key findings of the study, focusing on the finding of five mechanisms of the refined programme theory as these are central to understanding how outcomes were generated. Beyond demonstrating the effectiveness of this particular respite facility, these findings point to the benefits of crisis services being staffed by volunteers and operating as charitable organisations.

After outlining the limitations of this study, we discuss how several of the key mechanisms are enhanced by the charitable organisation structure and the use of non-professional volunteers. These findings are in opposition to a trend in the crisis intervention literature towards promoting the formalisation of crisis resolution services along with the professionalisation of staff. We discuss these apparent tensions between volunteerism and professionalisation, and make the argument that charitable organisations and non-professional volunteers should be viewed not as merely useful additions in the field of crisis intervention but as bringing unique advantages that contribute to positive outcomes. This discussion is then connected to the broader debate about distinctiveness in the voluntary sector.

Research design and methods

Realist evaluation is a form of theory-driven evaluation. This approach views interventions as ‘theories incarnate’ (Pawson and Tilley, 2004: 3) and focuses on developing, testing and refining theories that explain how an intervention works (Pawson and Tilley, 1997). As such, realist evaluation can be contrasted with the more common ‘black box’ approach to evaluation, which aims to prove whether there is a causal relationship between an intervention and various outcomes, without explaining how this relationship operates (Astbury and Leeuw, 2010).

Realist evaluation conceptualises programme theory (that is, theory that explains how an intervention or policy functions) as mechanisms functioning in particular contexts to generate outcomes. This central idea of the realist evaluation approach is summarised in the seemingly simple formula: context + mechanism = outcome (Pawson and Tilley, 1997). Mechanisms can be understood as the underlying entities, processes or structures that generate observable phenomena (Astbury and Leeuw, 2010: 368). These mechanisms may be material, emotional or cognitive (Maxwell, 2012). Context refers to the factors or circumstances in which mechanisms operate and which serve to facilitate or constrain the function of various mechanisms (Pawson, 2006). Finally, outcomes are the intended and unintended consequences of mechanisms operating in particular contexts (Pawson and Tilley, 2004).

A realist evaluation follows a retroductive process involving abduction, deduction and induction. This begins with the use of abductive reasoning (inference to the best available explanation) in order to generate an initial programme theory (Pawson and Tilley, 2004). The realist evaluation then deductively tests and inductively refines that theory (Salter and Kothari, 2014). To the extent that the refined programme theory resulting from this retroductive process is formulated at a middle range of abstraction (that is, between situation-specific hypotheses and overarching ‘grand theory’), it enables theoretical – rather than empirical – generalisations (Merton, 1968; Lewis et al, 2014). As such, realist evaluations can provide valuable guidance to policy makers and programme coordinators regarding the design and implementation of similar interventions in other settings (Mark et al, 1998).

Developing programme theory in this study involved two phases of data collection and analysis. A total of 35 participants were involved in these two phases: 22 guests and 13 staff. Of the participants: 23 were female and 12 were male; their ages ranged from 17 to 71 years old, with a mean age of 44.2; and the ethnicities of participants were: New Zealand European (17); Māori (nine); Other European (eight); and Asian (one).

In phase one, an initial programme theory was abductively inferred following a review of academic literature (crisis intervention theory and theories of suicide), analysis of grey literature (key policy and procedure documents from the Taranaki Retreat) and interviews with six of the Taranaki Retreat’s programme designers. In phase two, that initial theory was tested and refined using qualitative data gathered from participant observation, a focus group with staff and volunteers, interviews with 17 former guests and a review of the case notes of these guests. Participants in the focus group and interviews were presented with the initial programme theory for their critical reflections. The schedule for participant observation was designed around the initial contextual factors, mechanisms and outcomes. The use of these different methods provided diverse evidence for testing and refining the theory and enabled the triangulation of data (Baillie, 2015).

Thematic analysis was the primary method of analysing data in this study. Thematic analysis is a flexible approach – both in its ability to analyse various kinds of data and also in that it is not bound to any particular theoretical framework (Braun and Clarke, 2006; Joffe, 2012). Applying this method so that the overall analysis was retroductive involved using thematic analysis both deductively and inductively. Developing a generative explanation also involved using two additional methods: the technique of developing ‘profiles’ from data (Seidman, 2006) and concept mapping (Novak and Gowin, 1984; Miles et al, 2014). Profiles involved creating summaries of interview transcripts, while retaining the participants’ words and first-person narrative. This method made seeking associations and conditional statements in the data more manageable. Concept mapping also aided analysis of connections in the data. This approach generates visual representations of key concepts and processes (Miles et al, 2014: 20–7). Unlike thematic mapping, which simply presents a spatial arrangement of themes, concept mapping displays the relationships between concepts (Maxwell, 2012). Through iterations of written analysis and diagramming, the relationships illustrated in the conceptual maps were more fully explained by the accompanying narrative (Maxwell, 2012). The rigour of this study’s data analysis was supported by peer examination of coding and discussion between the authors of the emerging themes. Direct quotations from guest participants and staff participants (including volunteer staff) will be included in this article to support our interpretations of the data.

Findings

The refined programme theory that emerged from the two phases of data collection and analysis identified the key outcomes of this intervention, and furthermore identified five key mechanisms that, operating in different contexts, explain how these outcomes were generated. Figure 1 provides a visual display of the refined programme theory and illustrates the connections between the key contextual factors, mechanisms and outcomes. We summarise the identified outcomes along with the key contextual factors, before focusing in more detail on the five mechanisms that explain how these outcomes were generated.

Figure one displays the five mechanisms operating within the key contextual factors to generate the outcomes of this crisis intervention.
Figure 1:

refined programme theory

Citation: Voluntary Sector Review 2022; 10.1332/204080521X16346520274134

Participants who had stayed at the Taranaki Retreat as guests experienced five interrelated outcomes during, and in the months after, their stay. A reduction of emotional distress, reduced suicidality and restored clarity of thought were the three most prevalent outcomes reported by guests. Participants who had experienced disturbed sleep and/or functional impairment prior to their stay reported outcomes of improved sleep and restoration of daily functioning (for example, the ability to drive or study). Collectively, these five outcomes represented the resolution of guests’ state of crisis. While the findings of this study indicate the ability of this respite centre to facilitate a restored state of equilibrium, they also indicated that the respite centre did not directly help guests develop additional coping skills or new interpretations of stressor events.

A total of 12 key contextual factors were identified in this study of Taranaki Retreat. These factors can be placed into three categories: initial stressors; the state of crisis; and secondary stressors. Initial stressors were broadly divided into situational stressors (for example, the death of a family member or a relationship break-up) and non-situational stressors (including a more long-term sense of purposelessness or lack of fulfilment). The state of crisis consisted of: emotional distress; impaired clarity of thought; suicidality; disturbed sleep; and functional impairment. Finally, the secondary stressors included: agitation at daily surroundings; engaging in unhelpful behaviours; an unfulfilled need for acknowledgement of distress; an unfulfilled need to be offered genuine care; and an unfulfilled need for allies. The initial stressors play an important role in triggering the state of crisis. The state of crisis itself then generates secondary stressors, or at least exacerbates these issues to the extent that they become stressors. In turn, secondary stressors compound the state of crisis. ‘Initial stressors’ therefore refers to circumstances that precede the state of crisis, whereas ‘secondary stressors’ arise during the state of crisis.

The study identified five key mechanisms that, operating in the above contexts, generate the retreat’s outcomes. These mechanisms were identified, tested and refined over two phases of data collection and analysis. Each of these mechanisms will be discussed in greater detail below, but to summarise, their primary function is to remove the amplifying effect that secondary stressors are having on guests’ state of crisis. Two of the mechanisms involve the removal of something that is agitating or otherwise unhelpful, namely: ‘time out from daily surroundings’ and ‘the interruption of unhelpful behaviours’. The three remaining mechanisms involve the fulfilment of a previously unmet need, namely: ‘acknowledgement of distress’; ‘offers of genuine care’; and ‘the presence of allies’. These two groupings of mechanisms can be referred to – only somewhat metaphorically – as ‘quiet’ and ‘warmth’, respectively. These two abstracted themes, along with the five key mechanisms, were generated from our interpretation of the data – using terms that captured the essence of the data being coded, rather than from the direct language of participants or from existing literature.

Time out from daily surroundings

Of the five mechanisms identified in this study, the provision of ‘time out’ is perhaps the one most closely aligned with common notions of the function of respite. Indeed, this function is captured both in the general definition of respite as ‘an interval of rest or relief’ (Mirriam-Webster, no date) and in the retreat’s motto: ‘space to breathe’. A number of participants – guests and staff – identified this mechanism as foundational. It was considered to come into effect ‘first’ and to be a prerequisite to the other mechanisms:

‘The time out thing – I see it as a concrete basis. The other [mechanisms] stand on top of the time out’ (Staff 1)

This mechanism consists of two elements: removing the guest from their regular environment and providing a new environment. With reference to the first element, guest participants often found their daily surroundings to be agitating. The aspects of their environments that they found agitating and from which they were removed included: reminders of a loss; the behaviour of family members, colleagues and others; interactions on social media; and regular daily tasks.

‘I needed to get away from here, get away from people. … That’s what it was for us – it was just somewhere different. Different environment … Just that difference from where we were, I believe made a difference for us, moving forward. Getting out of that mess.’ (Guest 2)

‘[The retreat stay] just gave me that opportunity to have that time out from my kids, from that [home] atmosphere.’ (Guest 14)

The second element (the provision of a new environment) is facilitated through the retreat’s physical site: the rural setting; the site’s landscape; and the various buildings onsite. This new environment lacked those agitating aspects and contained features that guests found calming, such as the natural setting, the gardens, quiet spaces to sit and be alone, walking tracks around the site and being around animals:

‘The quietness was great. And then the mountain – something about that mountain. It just … you could just sit there for hours looking at it. It’s very calm.’ (Guest 1)

‘You couldn’t see the road, you didn’t have to worry about people coming and going, because the only things that came and go was the damn goat that kept getting out of its pen! … So, in a way, the way that it’s been built, it cuts you off from everything, so you can relate to what you’re feeling yourself.’ (Guest 3)

‘That sort of lifestyle block, you know, coming from the city where you don’t, you know, you don’t get to experience that – it was quiet and calm.’ (Guest 13)

For most of the guest participants, this mechanism generated a calming response – a reduction of agitation. For guest participants who had been assaulted or had experienced interpersonal conflict prior to their stay, this time out brought an added feeling of safety. However, for guests who were accustomed to a busy lifestyle, time out could initially be quite confronting.

‘I’d been [at the retreat] two days and [my colleague] texts me: “How you doing?” And I’m just like: “I have literally got nothing to do. I don’t know what to do.” And she was like, in capital letters: “LEARN TO RELAX”. Because I’m not very good at that. I spend all day racing in circles around here.’ (Guest 10)

Interruption of unhelpful behaviours

During their state of crisis, and in the period just prior to staying at the retreat, many of the guest participants engaged in various forms of coping behaviours that limited their ability to adjust to challenging situations and ultimately compounded their distress. For these participants, staying at the retreat (that is, being removed from their regular environment and provided with a new environment) interrupted, limited or even prevented these unhelpful coping behaviours. For guest participants who were not engaging in unhelpful coping behaviours, this mechanism had no effect.

A number of guest participants described isolating themselves in their bedrooms or at home for days at a time, or longer. These participants had this behaviour interrupted by staying at the retreat. Other guest participants reported using excessive activity as a means of distracting from their distress. Staying at the retreat interrupted this pattern as well.

‘It’s a good thing – it’s just a learning thing – [guests] have to start thinking: “I don’t have to do the washing, I don’t have to cook a meal” and “What does that mean? What am I to think about now?” Because people are so used to distracting [themselves] and saying: “I have to do this.” Some people – not everybody – have developed these behaviours of just constantly kind of distracting, to keep these feelings away.’ (Staff 7)

The retreat’s zero tolerance of alcohol or illicit drugs also restricts heavy substance use among guests. A number of participants recognised that the removal of easy access to alcohol and other drugs while at the retreat was helpful:

‘I think the no drugs and no alcohol thing helped, you know, because let’s face it – a lot of our problems are linked with something, aren’t they? But, if it’s not accessible, then it’s something that is … it’s taken out of your control almost. You know what I mean. I think that’s a really good thing … At the retreat, I mean there was none of that there, so you didn’t need to deal with it.’ (Guest 7)

Two of the guest participants reported using self-harm as a means of coping with their distress. Neither of them was self-harming while at the retreat. However, it remains less clear that a retreat stay would directly prevent or reduce self-harm in the same way it does other unhelpful behaviours. Guests are given individual rooms that can be locked from the inside and the retreat has a deliberate policy of not inspecting guests’ belongings upon arrival. These policies appear to support the unobtrusiveness of the care received, but they also do not serve to directly interrupt instances of self-harm. While the retreat takes safety precautions (such as storing work tools securely) its impact on self-harm appears to be indirect – secondary to the reduction of guests’ distress.

Acknowledgement of distress

In the context of guest participants viewing those around them as not acknowledging or even noticing their distress, a key mechanism for this intervention was guests’ interpretation that their distress had been acknowledged and their situation was being taken seriously. The fulfilment of this previously unmet need for acknowledgement relieved some of the distress guest participants were experiencing. This acknowledgement is similar to, yet still distinguishable from, the concept of validation. Whereas validation communicates to the distressed person that their thoughts, feelings and behaviours are understandable within the context of their current situation (Linehan, 1993), acknowledgement of distress – as described by guest participants – instead communicated to them: “You matter to me.”

An important factor in this acknowledgement of distress appears to be the retreat’s acceptance (indeed, encouragement) of self-referrals. Guest participants were able to directly request help without having to first justify the need for this request to a health professional. The retreat’s use of minimal exclusion criteria also appears to minimise the need for referrers to prove ‘worthiness’ for care. Another important factor was how this initial contact was handled and the seriousness with which guest participants’ situations were treated.

‘[The staff member] really made an impression on me, over the phone. He didn’t muck around, you know. He said: “Mate, we need to get you here straightaway. What you’ve told me is serious.” It actually gave me hope. Just [him] saying that he was so determined to get me there.’ (Guest 1)

In fact, this mechanism appears to take effect from the point of first contact with the retreat. Staff participants indicated that there were people who did not require any further follow-up after the initial stage of contacting the retreat. This is a further indication of the impact this mechanism can have.

‘I’ve seen a lot of change happen prior to... you know, sometimes it doesn’t even get to the assessment point, because the simple act of reaching out and being heard has kicked things off straightaway for people’ (Staff 6)

A final factor that appears to support the interpretation that one’s distress had been acknowledged was the belief among guest participants that the retreat staff ‘got it’ (understood and empathised with their situation). This belief was enhanced by staff members openly sharing their own stories to demonstrate having shared experiences. It also appears to be supported by staff members’ non-professional status, which contributed to staff being viewed by guests as allies rather than experts. This factor will be further explored in the fifth mechanism, ‘the presence of allies’.

Offers of genuine care

The most prominent theme in the data – and seemingly the most significant mechanism in explaining how respite functions to support service users – is the fulfilment of the need to be offered genuine care. The term ‘genuine care’ refers to care that is interpreted by the intended recipient as being motivated by a genuine desire to help. All guest participants described being offered genuine care while at the retreat. They also described the large impact that the fulfilment of this need had in alleviating their distress. The core response to being offered genuine care was: “I matter to other people.” This response signifies not only the fulfilment of the need for genuine care, but it also addresses the initial stressor of feeling unvalued. As such, it had a significant impact in alleviating the distress of guest participants.

‘[The retreat staff] blow you away with just genuine love and concern and care.’ (Guest 1)

‘[The most important thing was] the fact that someone really did care. That’s how they came across. … You were treated, you were just treated well. They make you feel important, that you matter.’ (Guest 7)

Supporting the formulation that the effective mechanism is the offer of genuine care, rather than the care itself, is the observation that the impact was present regardless of whether or not the guest participant made use of whatever was actually offered. For example, the awareness among guest participants that they could approach and talk to staff at any time was impactful, even when it was not acted upon. Furthermore, guest participants’ accounts of this care focused much more on the fact that it was being offered, rather than on what they received.

The guest participants’ interpretation that the care they were offered was motivated by a genuine desire to help appears to be based on five features of that care. The first of these features was that the care provided by the retreat was experienced as accessible – a feature that was facilitated by the retreat’s acceptance of self-referrals and its minimal use of exclusion criteria.

Second, the care offered by the retreat was seen by participants as comprehensive. This included: a wide selection of activities; no time limits on conversations with staff; follow-up care; the possibility of additional or extended stays; and other unexpected gestures. Participants contrasted this with their previous experiences of care as perfunctory and ‘the bare minimum’ (such as five-minute appointments with a general practitioner, or contact with mental health professionals who were seen as “only there because it’s their job”).

Third, participants – particularly those who had used mental health services in the past – noted a flexibility in the care they received at the retreat. They felt it was offered non-forcefully and without an agenda. There was also flexibility in the retreat’s policies and procedures. While the length of each guest’s stay was clarified beforehand, this could be extended in some circumstances. During the stay, there was a general schedule and a wide range of activities on offer, but participation in both was optional. Some participants shared the view that being a non-governmental organisation is what enables this flexibility, and that publicly funded services lacked flexibility due to their focus on minimising risk and meeting performance targets.

‘I think what’s needed to make [a respite facility] work is to keep the government out of it. I know [not having government funding] can be kind of hard, but when I look at what they’ve got [at the retreat], why it’s so successful is because it’s run purely on donations – fundraising and sponsorship and stuff like that … It’s a great model. But when you start getting funding from the government to do it, you have boxes that you need to tick in order to carry on with that funding. And that’s what I think takes away from that personal touch a bit, if that makes sense.’ (Guest 13)

Another factor that contributed to participants interpreting the care as genuine was the belief that it was being offered selflessly. Guest participants observed that there were ‘no strings attached’ to the care they received – that the respite stay was free of charge and was provided without any expectation that guests gave back. Participants also commented that the care seemed to involve some sacrifice, which supported their view that it was selfless. This sacrifice included the fact that many of the staff volunteered their time:

‘Maybe that’s where the government-funded side falls down, because they’re not in it because they care, you know. They’re there because it’s a job, and maybe that’s the difference.’ (Guest 7)

‘Just seeing how they, you know, what they give and what they do for their community and for people like me … Just the fact that they’re kind of like, they’re doing that voluntarily. So, you actually feel like they’re really there because they care.’ (Guest 13)

‘[The retreat staff are] not … like it’s a job, but it’s all like donations and stuff. Like they’re just doing it to help people. They’re not doing it to get something out of it for themselves … So, it was really different for me to meet [these people] who, like, just want to give and don’t want to take anything from you, and there’s no expense.’ (Guest 17)

A final feature that influenced participants’ interpretations of the care they were offered at the retreat was that the practical support and financial backing for the service ‘had a face’ (it was visible, proximal and intentional). As mentioned, the retreat is a charitable organisation, supported by volunteer workers and donations. This support is visibly acknowledged around the retreat site. Participants also observed members of the local community regularly visiting the retreat to donate food and other supplies, as well as seeing volunteers doing cleaning and maintenance jobs onsite.

‘I just couldn’t get over the amount of sponsors and … just the support. … I guess the thing I felt was: ‘Man, there are people out there who care’’ (Guest 1)

In addition to this support being visible, it is also proximal in the sense that the volunteers and donors come from the local community. The fact that this backing came from nearby appeared to contribute to the tangibility of the support:

‘The Taranaki people are good people. It’s not just [the retreat staff]. That gives them the power to do what they do – it’s the sheer support they’ve got – it’s phenomenal. … Just the generosity of the Taranaki people. It’s quite humbling. I was determined to get well. And I think that helped because I thought this whole community is behind these people.’ (Guest 1)

Finally, participants noted the intentionality of this support – the fact that volunteers and donors had chosen to support the service provided to guests. This could be contrasted with the lack of intentionality from taxpayers when publicly funded facilities are allocated resources. Participants felt that those supporting the retreat were deliberately and personally trying to help them out of their distress:

‘It’s amazing how a place like that runs. Since it’s supported by the community basically. I find that just amazing. The people give so much for us … People you don’t know, you are grateful to’ (Guest 2)

The presence of allies

The final mechanism and a key theme from the data was guest participants’ interpretation that they had allies during their stay at the retreat. This, again, served to fulfil a previously unmet need. Additionally, this mechanism – as with the two previous mechanisms – also helped to address the initial stressor of ‘feeling unvalued’. It did so by communicating to guest participants: “You matter – we are here to support you.”

An important factor contributing to the interpretation of having allies was the relatability of the retreat staff. Many of the staff shared similar experiences with guests, and they communicated these shared experiences openly. The non-professional status and informal presentation of staff also appeared to contribute to guests viewing staff as allies, rather than experts. Several of the guest participants directly contrasted this relatability with their experience of mental health professionals:

‘When I saw [support worker] walk through the door, I knew he was real … Straight away when I seen him, I was like: ‘I’m going to listen to you. You’re totally different to the suits and the flash cars that I’ve had to talk to’’ (Guest 16)

Although guest participants’ experiences with fellow guests were variable, the sense of having shared experiences extended beyond the staff. Many of the guest participants also experienced the other guests as allies and the guests supported each other:

‘Being around other people that are going through similar situations … Trying to find that sort of inspiration from each other. I think that really helped … I mean I still keep in contact with the [other guests] that I stayed with, so I think that made a big difference.’ (Guest 13)

This mechanism was important for those guests who had a previously unmet need for allies (a key contextual factor). However, a number of the guest participants did not express an unfulfilled need for allies prior to their stay at the retreat. Among these participants, there were several who did not experience the presence of other guests and staff positively. One guest participant felt a pressure to act sociably and described the regular interactions as energy-sapping. In the absence of an unfulfilled need for allies, several guest participants placed much higher emphasis on having ‘time out’.

‘Being in a house with other people – you’ve sort of got to put that effort into living, communing together. Instead of just having that absolute time out. You’ve got to put some of your energy into interacting with other people who you usually wouldn’t.’ (Guest 14)

Discussion

The findings of this study support the use of respite as part of a spectrum of crisis resolution services. Comprehensive, non-clinical services such as respite should receive greater attention in the ongoing discussion of how to better meet the needs of people experiencing suicidality and acute distress.

The findings of this study are subject to several limitations, however. One threat to the validity of this study is self-selection bias and the possibility that guests with more favourable experiences at the retreat were more inclined to participate. Furthermore, as the findings of this study are based on data gathered from a single service and did not involve a large number of participants, this limits the study’s empirical generalisability. It should be noted, however, that this realist evaluation aimed for theoretical generalisability rather than empirical generalisability. Whereas empirical generalisability refers to the applicability of a study’s findings to other populations or settings, based on similarities between those populations and settings (Lewis et al, 2014), theoretical generalisability refers to the applicability of a theory to other settings, based on the generality of that theory (Maxwell, 2017). As such, realist evaluations can provide valuable guidance to policy makers and programme coordinators regarding the design and implementation of similar interventions in other settings (Mark et al, 1998). This study achieved theoretical generalisability by formulating a programme theory at a level of abstraction that is applicable to other similar crisis services.

Volunteers and charitable organisations in crisis intervention

The vast majority of crisis intervention work is performed by volunteers. Within crisis services, volunteers are estimated to outnumber paid staff at a ratio of six to one (James and Gilliland, 2017). However, in the crisis intervention literature, frequent calls are made for the professionalisation of this field (Roberts and Ottens, 2005; Puleo and McGlothlin, 2010; James, 2016; Yeager and Roberts, 2016). James and Gilliland (2017: 5–7) argue that while volunteerism is an important and useful means of initiating crisis services, it is ultimately inadequate for managing the complexity of this work. They view the life experience that volunteers often bring as a potential advantage, but also as a potential source of ‘emotional baggage’ that impairs their ability to effectively perform their role (James and Gilliland, 2017: 23). It is therefore argued that volunteers who work in crisis services must receive specialised training (Roberts and Ottens, 2005; Puleo and McGlothlin, 2010).

James and Gilliland (2017: 6) also make the argument that as the number and needs of service users increase, volunteers become unable to manage the complexity of the presenting issues. These authors do not explain why the needs of service users would inevitably become more complex over time. From their outset, crisis services are likely to support people presenting with needs of varying complexity. Furthermore, while the scope of a service may broaden (or narrow), this would be a controlled and gradual process determined by the coordinators of the service. A sudden shift to an entirely different client base with much more complex needs appears unlikely. Similarly, these authors do not explain how an increased number of service users, in and of itself, will exceed the capacity of volunteers. The challenge of more service users could presumably be met with a greater number of volunteers.

The claim that volunteers are less capable of supporting people in crisis than health professionals is at odds with the findings of this study, which indicate that volunteerism enhances key mechanisms of change (specifically, the mechanisms ‘acknowledgement of distress’, ‘offers of genuine care’ and ‘the presence of allies’). These findings can be viewed within a broader discussion in the voluntary sector literature about the distinctiveness of voluntary organisations and the unique contributions these organisations make. Among the attributes commonly identified as characteristic of voluntary organisations are flexibility, innovativeness and an ability to reach the most disadvantaged populations (Macmillan, 2013). Voluntary organisations are also thought to place greater emphasis on relational qualities such as kindness and compassion (Newbigging et al, 2020). It should be noted, however, that while claims about the distinctiveness of voluntary organisations are widespread, there is a body of research that contests or complicates such claims (Macmillan, 2013: 45–8).

Although the potential merits of professionalisation warrant further examination, it is also worth considering possible motivations for the push towards professionalisation. In the field of mental health, longstanding critiques have been made that professional groups (in particular, psychiatry) are motivated by a desire for legitimacy and authority (Szasz, 1982; Thomas and Bracken, 2004). Similar critiques could arguably be directed towards the efforts to professionalise the field of crisis intervention. James and Gilliland (2017: 7) describe crisis intervention as transitioning over recent decades from a ‘psychological backwater’ to a specialised and professionally acknowledged area of practice. The potential desire for legitimacy and authority in a particular field is not, by itself, a reason to dismiss the promotion of professionalisation. It would, however, provide important context for examining and interrogating this trend.

In addition to being at odds with the findings of this study, the criticisms of volunteerism in recent crisis intervention literature also appear at odds with the origins of crisis intervention. When crisis intervention began to emerge as a distinct field of practice, Gerald Caplan highlighted the fact that untrained community helpers are capable of undertaking this work (Caplan, 1990; Puleo and McGlothlin, 2010). Indeed, crisis intervention was viewed as a means of avoiding pathology and the need for clinical input (Caplan, 1990). The crucial role of volunteers was echoed by a number of other original contributors to this field (McGee, 1974; Golan, 1978). In the context of the push towards professionalisation, this study suggests that crisis intervention needs to ‘return to its roots’.

Given that health professionals are able to volunteer their services, and that people without formal training can work in paid roles, it is useful to distinguish between volunteers and non-professionals. This study demonstrated that people who are not health professionals are able to meet the needs of people in crisis and facilitate crisis resolution. In doing so, the study challenged the idea that crisis services are ideally provided by health professionals. In addition to this, the study illustrated that both the volunteer aspect and the non-professional aspect appear to bring distinct and important advantages. Volunteers are not merely a useful addition, or a source of free labour – they are central to positive outcomes. As discussed in the findings section, the volunteer status of most of the Taranaki Retreat staff contributed significantly to the mechanism ‘offers of genuine care’. In particular, three of the features that supported ‘offers of genuine care’ (‘visible, proximal and intentional backing’, ‘selfless’ and ‘flexible’) all appear to be connected to, or enhanced by, the Taranaki Retreat operating as a charitable organisation staffed largely by volunteers.

The non-professional status of almost all of the retreat’s staff was also important. In particular, this appeared to reduce the divide between staff members and guests, consequently enhancing the mechanism ‘the presence of allies’. Guest participants viewed the retreat staff as allies who could relate to their experiences, rather than as experts there to treat them. This relatability, combined with retreat staff openly sharing their own experiences, also enhanced ‘acknowledgement of distress’, as guest participants felt that the staff clearly understood and empathised with their situations.

These findings align with the argument that voluntary organisations have a comparative advantage over public and private organisations, due to the trait of ‘stakeholder ambiguity’ (Billis and Glennerster, 1998). Stakeholder ambiguity refers to the common lack of sharp distinctions – and often overlapping roles – between groups of stakeholders in voluntary organisations (Billis and Glennerster, 1998; Macmillan 2013). This ambiguity produces comparatively flat hierarchies and predisposes these organisations to respond to the experiences of service users in a more sensitive and non-judgemental manner (Newbigging et al, 2020).

Aside from contributing to improved quality of crisis services, there is also the practical consideration that the use of volunteers who are not health professionals significantly increases the quantity of potential crisis workers and crisis services. Although volunteers already operate in crisis services such as telephone hotlines, more comprehensive services (such as respite), which are likely to support people in a greater degree of distress, may be assumed as the domain of health professionals. Dismissing the idea that only health professionals can provide comprehensive care for people who are experiencing acute distress and suicidal thoughts (an idea that corresponds with the medicalisation of distress and suicidality) may unlock significant ‘untapped potential’ within local communities. Acute distress, even when not accompanied by mental illness, warrants a satisfactory response. With greater encouragement and utilisation of non-professional volunteers, there could be a growth of localised comprehensive crisis services and therefore more options for people experiencing acute distress. It should be noted that dismissing the idea that only health professionals can provide comprehensive crisis care does not involve dismissing the seriousness of behavioural emergencies. The latter involve imminent risk of harm and generally require the involvement of clinical services (Kleespies, 2009).

Associated with the push towards professionalisation is the idea that as crisis services grow, they will and should inevitably institutionalise, or become more formalised (James and Gilliland 2017). Those services that are able to maintain their initial funding and achieve a degree of recognition may go on to secure government funding and begin to implement changes such as requiring staff to gain professional registrations (Walsh, 2013). In New Zealand, this process has meant that the title ‘non-governmental organisation’ at times appears a misnomer, as the agency referring to itself as such may be entirely funded by a government department or district health board, with clear directions and expectations attached to that funding. While government funding provides a degree of financial security that charitable organisations generally lack, there does not appear to be much consideration in the crisis intervention literature as to whether anything is lost through this process of formalising crisis resolution services.

This study did not evaluate publicly funded crisis services, and as a result cannot make decisive claims about the comparative advantages and disadvantages of charitable and publicly funded organisations. However, the study does demonstrate how key mechanisms are supported by features that publicly funded services generally do not possess. The potential loss of these features (and thus the loss of the mechanisms they support) should be taken into greater consideration in the discussion around professionalising crisis services.

Conclusion

This study developed a generative explanation of how respite functions to support people who are experiencing a state of crisis. As a realist evaluation, it not only identified the key contextual factors, mechanisms and outcomes of the Taranaki Retreat, it also developed a transferable theory that is potentially applicable to crisis resolution services more broadly. In the face of international concern about the prevalence of psychological distress and suicidality, as well as the oft-discussed failure of clinical services to adequately meet the needs of people in crisis, the theory developed in this study serves the purpose of supporting the improvement of crisis resolution services. The study points to the largely overlooked potential of non-clinical, community-based organisations to provide comprehensive support to people experiencing acute distress and suicidality. Greater attention to, and support of, respite as a means of crisis resolution would strengthen and widen the spectrum of crisis services.

Standing in opposition to current trends in the crisis intervention literature advocating for the professionalisation of this field of practice, this study highlights the distinct value of both charitable organisations and volunteerism in achieving positive outcomes for people in crisis. The potential loss of these distinct benefits through the formalisation and professionalisation of this field requires greater consideration.

Future research could include further testing of the programme theory in other comparable crisis respite facilities, as well as using components of this theory to aid theory-building efforts with other ‘non-respite’ crisis services. Although the rarity of respite facilities specifically for people experiencing suicidality and/or distress (as opposed to acute mental illness) currently limits the opportunity for comparative studies, in future, if possible, it would be beneficial to compare charitable and publicly funded crisis respite services, and compare crisis services staffed by non-professional volunteers with those staffed by paid health professionals.

Funding

This work was supported by the University of Otago doctoral scholarship.

Acknowledgements

The authors would like to thank Dr Justin Jagosh for his valuable input regarding the use of realist evaluation as a methodological framework and Dr Rachelle Martin for her assistance in the peer review of coding. We also wish to thank the guest participants in this study along with the staff and trustees of Taranaki Retreat.

Conflict of interest

The authors declare that there is no conflict of interest.

References

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    • Search Google Scholar
    • Export Citation
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    • Search Google Scholar
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    • Search Google Scholar
    • Export Citation
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  • Merton, R.K. (1968) Social Theory and Social Structure, New York, NY: Free Press.

  • Miles, M.B., Huberman, A.M. and Saldaña, J. (2014) Qualitative Data Analysis: A Methods Sourcebook, Thousand Oaks, CA: SAGE Publications.

    • Search Google Scholar
    • Export Citation
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    • Search Google Scholar
    • Export Citation
  • Newbigging, K., Rees, J., Ince, R., Mohan, J., Joseph, D., Ashman, M., Norden, B., Dare, C., Bourke, S. and Costello, B. (2020) The contribution of the voluntary sector to mental health crisis care: a mixed-methods study, Health Services and Delivery Research, 8(29): 1199. doi: 10.3310/hsdr08290

    • Search Google Scholar
    • Export Citation
  • Novak, J.D. and Gowin, D.B. (1984) Learning How to Learn, Cambridge: Cambridge University Press.

  • Pawson, R. (2006) Evidence-based Policy: A Realist Perspective, London: SAGE Publications.

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    • Search Google Scholar
    • Export Citation
  • Roberts, A.R. and Ottens, A.J. (2005) The seven-stage crisis intervention model: a road map to goal attainment, problem solving, and crisis resolution, Brief Treatment and Crisis Intervention, 5(4): 32936. doi: 10.1093/brief-treatment/mhi030

    • Search Google Scholar
    • Export Citation
  • Salter, K.L. and Kothari, A. (2014) Using realist evaluation to open the black box of knowledge translation: a state-of-the-art review, Implementation Science, 9(115): 114. doi: 10.1186/1748-5908-9-1

    • Search Google Scholar
    • Export Citation
  • Seidman, I. (2006) Interviewing as Qualitative Research: A Guide for Researchers in Education and the Social Sciences, New York, NY: Teachers College Press.

    • Search Google Scholar
    • Export Citation
  • Sheppard, R., Deane, F.P. and Ciarrochi, J. (2018) Unmet need for professional mental health care among adolescents with high psychological distress, Australian & New Zealand Journal of Psychiatry, 52(1): 5967.

    • Search Google Scholar
    • Export Citation
  • Singh, P., Chakravarthy, B., Yoon, J., Snowden, L. and Bruckner, T.A. (2019) Psychiatric‐related revisits to the emergency department following rapid expansion of community mental health services, Academic Emergency Medicine, 26(12): 133645. doi: 10.1111/acem.13812

    • Search Google Scholar
    • Export Citation
  • Szasz, T. (1982) On the legitimacy of psychiatric power, Metamedicine, 3(3): 31524. doi: 10.1007/BF00900933

  • Taylor, T.L., Hawton, K., Fortune, S. and Kapur, N. (2009) Attitudes towards clinical services among people who self-harm: systematic review, The British Journal of Psychiatry, 194(2): 10410. doi: 10.1192/bjp.bp.107.046425

    • Search Google Scholar
    • Export Citation
  • Thomas, P. and Bracken, P. (2004) Critical psychiatry in practice, Advances in Psychiatric Treatment, 10(5): 36170. doi: 10.1192/apt.10.5.361

    • Search Google Scholar
    • Export Citation
  • Turecki, G., Brent, D.A., Gunnell, D., O’Connor, R.C., Oquendo, M.A., Pirkis, J. and Stanley, B.H. (2019) Suicide and suicide risk, Nature Reviews Disease Primers, 5(1): 122. doi: 10.1038/s41572-019-0121-0

    • Search Google Scholar
    • Export Citation
  • Walsh, J. (2013) Theories for Direct Social work Practice, Stamford, CT: Cengage Learning.

  • Yeager, K.R. and Roberts, A.R. (2016) Bridging the past and present to the future of crisis intervention and crisis management, in K.R. Yeager and A.R. Roberts (eds) Crisis Intervention Handbook: Assessment, Treatment, and Research, Oxford: Oxford University Press, pp 335.

    • Search Google Scholar
    • Export Citation
  • Astbury, B. and Leeuw, F.L. (2010) Unpacking black boxes: mechanisms and theory building in evaluation, American Journal of Evaluation, 31(3): 36381. doi: 10.1177/1098214010371972

    • Search Google Scholar
    • Export Citation
  • Baillie, L. (2015) Promoting and evaluating scientific rigour in qualitative research, Nursing Standard, 29(46): 3642. doi: 10.7748/ns.29.46.36.e8830

    • Search Google Scholar
    • Export Citation
  • Billis, D. and Glennerster, H. (1998) Human services and the voluntary sector: towards a theory of comparative advantage, Journal of Social Policy, 27(1): 7998. doi: 10.1017/S0047279497005175

    • Search Google Scholar
    • Export Citation
  • Boscarato, K., Lee, S., Kroschel, J., Hollander, Y., Brennan, A. and Warren, N. (2014) Consumer experience of formal crisis‐response services and preferred methods of crisis intervention, International Journal of Mental Health Nursing, 23(4): 28795. doi: 10.1111/inm.12059

    • Search Google Scholar
    • Export Citation
  • Braun, V. and Clarke, V. (2006) Using thematic analysis in psychology, Qualitative Research in Psychology, 3(2): 77101. doi: 10.1191/1478088706qp063oa

    • Search Google Scholar
    • Export Citation
  • Bruffaerts, R., Demyttenaere, K., Hwang, I., Chiu, W.T., Sampson, N., Kessler, R.C., Alonso, J., Borges, G., de Girolamo, G., de Graaf, R. et al. (2011) Treatment of suicidal people around the world, The British Journal of Psychiatry, 199(1): 6470. doi: 10.1192/bjp.bp.110.084129

    • Search Google Scholar
    • Export Citation
  • Caplan, G. (1990) Loss, stress, and mental health, Community Mental Health Journal, 26(1): 2748. doi: 10.1007/BF00752675

  • Chiu, M., Vigod, S., Rahman, F., Wilton, A.S., Lebenbaum, M. and Kurdyak, P. (2018) Mortality risk associated with psychological distress and major depression: a population-based cohort study, Journal of Affective Disorders, 234 (July): 11723. doi: 10.1016/j.jad.2018.02.075

    • Search Google Scholar
    • Export Citation
  • Clarke, D.E., Dusome, D. and Hughes, L. (2007) Emergency department from the mental health client’s perspective, International Journal of Mental Health Nursing, 16(2): 12631. doi: 10.1111/j.1447-0349.2007.00455.x

    • Search Google Scholar
    • Export Citation
  • Coppersmith, D.D.L., Nada-Raja, S. and Beautrais, A.L. (2017) An examination of suicide research and funding in New Zealand 2006–16: implications for new research and policies, Australian Health Review, 42(3): 35660. doi: 10.1071/AH16189

    • Search Google Scholar
    • Export Citation
  • Elliott, M. (2017) People’s Mental Health Report Wellington, NZ: ActionStation.

  • Golan, N. (1978) Treatment in Crisis Situations, New York, NY: Free Press.

  • James, R.K. (2016) Crisis intervention, in J.C. Norcross, G.R. VandenBos, D.K. Freedheim and R. Krishnamurthy (eds) APA Handbook of Clinical Psychology: Applications and Methods, Washington, DC: American Psychological Association, pp 387407.

    • Search Google Scholar
    • Export Citation
  • James, R.K. and Gilliland, B.E. (2017) Crisis Intervention Strategies, Boston, MA: Cengage Learning.

  • Joffe, H. (2012) Thematic analysis, in D. Harper and A.R. Thompson (eds) Qualitative Research Methods in Mental Health and Psychotherapy, Chichester: Wiley-Blackwell, pp 20923.

    • Search Google Scholar
    • Export Citation
  • Kleespies, P.M. (2009) Behavioral Emergencies: An Evidence-based Resource for Evaluating and Managing Risk of Suicide, Violence, and Victimization, Washington, DC: American Psychological Association.

    • Search Google Scholar
    • Export Citation
  • Klevan, T., Karlsson, B. and Ruud, T. (2017) “At the extremities of life” – service user experiences of helpful help in mental health crises, American Journal of Psychiatric Rehabilitation, 20(2): 87105. doi: 10.1080/15487768.2017.1302370

    • Search Google Scholar
    • Export Citation
  • Lewis, J., Ritchie, J., Ormston, R. and Morrell, G. (2014) Generalising from qualitative research, in J. Ritchie, J. Lewis, C. McNaughton Nicholls and R. Ormston (eds) Qualitative Research Practice: A Guide for Social Science Students and Researchers, London: SAGE Publications, pp 34766.

    • Search Google Scholar
    • Export Citation
  • Linehan, M. (1993) Cognitive-behavioral Treatment of Borderline Personality Disorder, New York, NY: Guilford Press.

  • Macmillan, R. (2013) ‘Distinction’ in the third sector, Voluntary Sector Review, 4(1): 3954. doi: 10.1332/204080513X661572

  • Mark, M.M., Henry, G.T. and Julnes, G. (1998) A realist theory of evaluation practice, New Directions for Evaluation, 1998(78): 332. doi: 10.1002/ev.1098

    • Search Google Scholar
    • Export Citation
  • Maxwell, J.A. (2012) A Realist Approach for Qualitative Research, Thousand Oaks, CA: SAGE Publications.

  • Maxwell, J.A. (2017) The validity and reliability of research: a realist perspective, in D. Wyse, L.E. Suter, E. Smith and N. Selwyn (eds) The BERA/SAGE Handbook of Educational Research, London: SAGE Publications, pp 11640.

    • Search Google Scholar
    • Export Citation
  • McGee, R.K. (1974) Crisis Intervention in the Community, Baltimore, MD: University Park Press.

  • Merton, R.K. (1968) Social Theory and Social Structure, New York, NY: Free Press.

  • Miles, M.B., Huberman, A.M. and Saldaña, J. (2014) Qualitative Data Analysis: A Methods Sourcebook, Thousand Oaks, CA: SAGE Publications.

    • Search Google Scholar
    • Export Citation
  • Mirriam-Webster (no date) respite, www.merriam-webster.com/dictionary/respite.

  • Naghavi, M. (2019) Global, regional, and national burden of suicide mortality 1990 to 2016: systematic analysis for the Global Burden of Disease Study 2016, BMJ, 364(194): 111.

    • Search Google Scholar
    • Export Citation
  • Newbigging, K., Rees, J., Ince, R., Mohan, J., Joseph, D., Ashman, M., Norden, B., Dare, C., Bourke, S. and Costello, B. (2020) The contribution of the voluntary sector to mental health crisis care: a mixed-methods study, Health Services and Delivery Research, 8(29): 1199. doi: 10.3310/hsdr08290

    • Search Google Scholar
    • Export Citation
  • Novak, J.D. and Gowin, D.B. (1984) Learning How to Learn, Cambridge: Cambridge University Press.

  • Pawson, R. (2006) Evidence-based Policy: A Realist Perspective, London: SAGE Publications.

  • Pawson, R. and Tilley, N. (1997) Realistic Evaluation, London: SAGE Publications.

  • Pawson, R. and Tilley, N. (2004) Realist Evaluation, London: Cabinet Office.

  • Puleo, S. and McGlothlin, J. (2010) Overview of crisis intervention, in L.R. Jackson-Cherry and B.T. Erford (eds) Crisis Intervention and Prevention, Upper Saddle River, NJ: Pearson, pp 124.

    • Search Google Scholar
    • Export Citation
  • Roberts, A.R. and Ottens, A.J. (2005) The seven-stage crisis intervention model: a road map to goal attainment, problem solving, and crisis resolution, Brief Treatment and Crisis Intervention, 5(4): 32936. doi: 10.1093/brief-treatment/mhi030

    • Search Google Scholar
    • Export Citation
  • Salter, K.L. and Kothari, A. (2014) Using realist evaluation to open the black box of knowledge translation: a state-of-the-art review, Implementation Science, 9(115): 114. doi: 10.1186/1748-5908-9-1

    • Search Google Scholar
    • Export Citation
  • Seidman, I. (2006) Interviewing as Qualitative Research: A Guide for Researchers in Education and the Social Sciences, New York, NY: Teachers College Press.

    • Search Google Scholar
    • Export Citation
  • Sheppard, R., Deane, F.P. and Ciarrochi, J. (2018) Unmet need for professional mental health care among adolescents with high psychological distress, Australian & New Zealand Journal of Psychiatry, 52(1): 5967.

    • Search Google Scholar
    • Export Citation
  • Singh, P., Chakravarthy, B., Yoon, J., Snowden, L. and Bruckner, T.A. (2019) Psychiatric‐related revisits to the emergency department following rapid expansion of community mental health services, Academic Emergency Medicine, 26(12): 133645. doi: 10.1111/acem.13812

    • Search Google Scholar
    • Export Citation
  • Szasz, T. (1982) On the legitimacy of psychiatric power, Metamedicine, 3(3): 31524. doi: 10.1007/BF00900933

  • Taylor, T.L., Hawton, K., Fortune, S. and Kapur, N. (2009) Attitudes towards clinical services among people who self-harm: systematic review, The British Journal of Psychiatry, 194(2): 10410. doi: 10.1192/bjp.bp.107.046425

    • Search Google Scholar
    • Export Citation
  • Thomas, P. and Bracken, P. (2004) Critical psychiatry in practice, Advances in Psychiatric Treatment, 10(5): 36170. doi: 10.1192/apt.10.5.361

    • Search Google Scholar
    • Export Citation
  • Turecki, G., Brent, D.A., Gunnell, D., O’Connor, R.C., Oquendo, M.A., Pirkis, J. and Stanley, B.H. (2019) Suicide and suicide risk, Nature Reviews Disease Primers, 5(1): 122. doi: 10.1038/s41572-019-0121-0

    • Search Google Scholar
    • Export Citation
  • Walsh, J. (2013) Theories for Direct Social work Practice, Stamford, CT: Cengage Learning.

  • Yeager, K.R. and Roberts, A.R. (2016) Bridging the past and present to the future of crisis intervention and crisis management, in K.R. Yeager and A.R. Roberts (eds) Crisis Intervention Handbook: Assessment, Treatment, and Research, Oxford: Oxford University Press, pp 335.

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  • 1 University of Otago (Wellington), , New Zealand
  • | 2 Te Herenga Waka – Victoria University of Wellington, , New Zealand
  • | 3 University of Otago (Wellington), , New Zealand

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