A Short-Term Home Where People in Crisis Can Avoid the Hospital

Taylor is also a part-time employee, but when she needs to feel grounded, she checks in for a stay. In this case, she’d begun feeling depressed, dragging around her apartment in pajamas – a signal that darker moods loomed ahead. By the time we met, she was cheerful and talkative.

Nationally, 32 respite centers in 14 states offer peer-run services, mostly week-long stays, as an alternative to crisis centers or hospitals. They provide no clinical care but emphasize respect, empathy and hopefulness, which staff and guests say are often missing in psychiatric facilities.

Taylor has dissociative disorder. She hears voices, sees things that aren’t real, and sometimes becomes paranoid. After years on disability and multiple hospitalizations, she came to the respite and met people who were managing their mental health challenges. The six staff members are peers – people with “lived experience” with mental health issues who are trained and certified to work with others with similar histories. One key activity they offer is WRAP, or Wellness Recovery Action Plan, which guides people to identify their triggers and calming activities.

“We love you until you can love yourself: That’s what I was told when I came through the door,” says Taylor, who has learned to live with her voices and visions. “When I thought I was unlovable and couldn’t manage, they showed me I could.”

Taylor lives alone, works 30 hours a week, and has been off disability since March. She hasn’t been in a psychiatric hospital in five years. It sounds too good to be true, she says, “but it is true. Peer support works. I’d rather come here than to a hospital or anywhere else. Who better to teach me and support me than someone who’s already been there?”

Peer respite hits the mainstream

The nation’s first peer respite center, Stepping Stone, opened 24 years ago in Claremont, New Hampshire with a mission of offering people “a space and some good listeners to go through their ‘altered state’ without coercion and without anyone else imposing meaning onto their experience,” co-founder Shery Mead said in an email. In the years since, respites have slowly increased in number, becoming a cherished non-clinical option for several thousand people who stay in them each year.

In July, Oregon Gov. Kate Brown signed a bill championed by the Oregon Mental Health Consumers Association, creating its first four peer respite centers, each with annual funding of $750,000. The legislation, passed overwhelmingly, grants operational control to peer-run organizations, enabling them to be “fully independent, separate and autonomous.”

“We’re making history,” says Kevin Fitts, executive director of the consumers association. The law, he says, sets a standard that may help define the nature of peer respites going forward.

Peer respites are increasingly recognized as an alternative to hospitalization. A 2021 World Health Organization report called for “person-centered, recovery-oriented mental health services that protect and promote people’s human rights” and highlighted Afiya House, a peer respite in western Massachusetts.

Although research on peer respites is sparse — in part because there’s not widespread agreement on how to define them — the available evidence suggests that peer respite services reduce hospitalization. A 2018 study published in Psychiatric Services compared 401 respite center clients and 1,796 people who had a psychiatry-related hospital stay in New York City. The two groups had similar demographics, diagnostic profiles and Medicaid expenditures in the six months before the study.

In six months after their respite stay, Medicaid expenditures for the respite visitors on average were $19,000 less than for those who had a hospital stay, due in part to decreased follow-on hospitalization, the study found.

A rare, randomized trial in California in 2008 compared the outcomes of 393 adults who’d been civilly committed for an acute psychiatric crisis and entered either an unlocked peer-run crisis residential program or locked psychiatric facility. While many participants were lost to follow-up, the differences were still significant: People who went to the peer-run program reported a greater reduction in psychiatric symptoms and higher satisfaction.

Although respite capacity remains small, “it’s just growing in its own way and its own time,” says Chris Hansen, director of Intentional Peer Support, a widely used peer training program. “System change doesn’t happen overnight.”

‘Surround me with love and support’

One interview-based study, published in Psychiatric Rehabilitation Journal in 2020, found that peer respite guests reported a greater sense of belonging, safety and hope for the future. “I felt like I was kind of joining this temporary family,” one guest reported. “I realized I didn’t need to be locked in, I just needed people around me so that I could talk when I needed to, and they could just kinda surround me with love and support.”

The peer support concept emerged from the mental health consumer movement of the 1970s, which demanded an end to abusive treatment in psychiatric institutions. Decades later, wariness lingers between advocates of peer-run programs and the mental health agencies that fund them.

“There’s lots of activists out there who say we shouldn’t be taking any money from the system whatsoever. But then what would we do?” says Sera Davidow, director of the Wildflower Alliance, which operates the Afiya respite in western Massachusetts. Private funds can’t sustain operations, she says.

One funder required Afiya to document respite stays, but the program doesn’t want to keep files as in a clinical model. Instead, Afiya asks guests to list recovery goals and to track their progress. The forms are stored in a locked cabinet for recordkeeping only, Davidow says.

Nationally, 53% of peer respite funding comes from state behavioral health agencies and 28% from county or local agencies, according to a 2020 survey by Live and Learn, Inc., a California research and consulting firm. Respite stays – free for guests – typically aren’t covered by insurance because they don’t involve medical care or require a diagnosis. Some centers receive federal grants or private donations.

Georgia is a national leader in peer support, even though Mental Health America ranks the state dead last for access to mental health care. Peer-based programs evolved out of Olmstead v L.C., a 1999 landmark U.S. Supreme Court case that established the right of people with disabilities to receive state-funded services in the community rather than institutions. In the wake of the Olmstead case, the state of Georgia greatly expanded community behavioral health services.

Pandemic-related state budget cuts forced the non-profit Georgia Mental Health Consumer Network to close one of its five state-funded respite centers – but then the state gave the network federal funds, which will enable it to open a new respite in Augusta. The Georgia respites have an annual operating budget of about $400,000 each. “We don’t want to support crisis; we want to support wellness and recovery,” says Dana McCrary, who heads the state behavioral health Office of Recovery Transformation.

‘This place has saved my life’

Back at the Cartersville respite center, a last bit of morning coolness lingered in the thick summer air as Ryan Plott and Amber Chapman stepped off the back steps of the house for a “wellness walk.” They crossed the railroad tracks, waved to an older woman rocking on her porch alongside a furiously barking Yorkie, and passed the remains of a demolished bungalow, walking just far enough to get a bit of exercise and clear the mind.

It was the first activity of the day at the respite, where day visitors and overnight guests gather for art and cooking projects, emotional support groups and meetings based on 12-step principles. Guests aren’t required to participate – they’re free to relax in their rooms or just chat with other guests if they choose.

Plott, 39, who struggles with anxiety, has been sleeping of late on a friend’s sofa while he awaits approval for subsidized housing, an excruciatingly slow process he finds overwhelming. “I just had all this stuff laying on my mind, and I felt like I couldn’t think,” he told Chapman, a peer specialist.

Later that afternoon, Plott checked in, bringing a bag of clothes to the “Bird Room,” with its broad window facing the front yard and guest-painted birdhouses on the mantle. A few staff members and day visitors were in the kitchen, but otherwise the house was quiet.

“This place has saved my life more than once,” said Plott, who feared that the stress of his housing situation would bring on a crisis. “When I get to that point where things are breaking down and I feel like I can’t go on, I come here. Sometimes a week is all it takes to get refocused to go on.”

L.O.V.E. and other aphorisms

The Carterville house has the eclectic comfort of a bed-and-breakfast, albeit one with a penchant for aphorisms and guest-made artwork. In the living room, where day visitors or respite guests can use computers for job searches, rows of small photos on plastic-covered sheets express upbeat, handwritten sentiments: “Tough times don’t last.” “You deserve to heal.” “Never stop trying.”

When the kitchen phone trills, as it does day and night, a staff member brings it into a walk-in closet-turned-office. Anyone can call twice a day, for 20 minutes, to talk about anything, or to sit in silence knowing a person is on the other end.

The guiding principle, says director Jennifer Barnett, is “L.O.V.E. Listen openly. Open-ended questions. Validate a person’s feelings. Then you have Empathy.” Sometimes, she adds, “people just need to talk and be heard.”

Peer respites pride themselves on having few rules, beyond respect for others. At the four in Georgia, guests must be in the house between 1 am and 5 am. They are responsible for their own medication, if any, and are given the only key to a personal lockbox to hold it. Bedroom doors lock only from the inside.

During COVID, the respites added precautions. Guests and staff alike pause for a temperature check before entering, and with the spread of the Delta variant, masks are again required in common areas. The Cartersville center is using just two of its three bedrooms so no one has to share a bathroom.

The respites shut down briefly at the onset of the pandemic but continued to take phone calls. The consumer network created a virtual wellness platform to provide Zoom-based support, a resource expected to continue beyond the pandemic.

Georgia respites require prospective guests to have a “proactive conversation” with a staff member before their first stay to form a connection when they’re feeling well. Guests can stay one week every 30 days, although first-time guests have priority.

Nationally, about a third of peer respites take people who are homeless without restriction; others take a more nuanced approach, such as requiring guests to have a place to go when they leave, according to the Live and Learn survey. Some accept guests directly from emergency or crisis centers. Only a few exclude people experiencing suicidal ideation. Georgia respites don’t accept anyone on a sex offender registry and bar alcohol or other substances.

Centers gather information on outcomes through exit surveys. They often ask if guests reached a recovery goal or avoided a hospital stay, but not about symptoms or diagnoses.

Evaluating clinical outcomes is problematic because, by definition, respites are non-clinical. “We still have work to do in defining what a respite is,” says Bevin Croft, research associate at the Human Services Research Institute in Cambridge, Massachusetts. “It’s hard to measure the effectiveness of something when it means different things to different people.”

Good Listeners, No Coercion

Respite centers have their challenges. The home-like environment creates a sense of comfort, but neighbors often resist them. The Cartersville respite planned to move to a larger house down the street but backed off when a nearby shop owner complained.

When Georgia’s first respite opened in 2008 in a house in an Atlanta suburb, neighbors objected, especially when they saw vanloads of day visitors dropped off by group homes for activities. Staff members weren’t happy about the vans, either.

“They wanted to treat our center like a day program but that’s not what we are,” says Roslind Hayes, statewide coordinator of the consumer network’s Peer Support, Wellness, and Respite Centers. Choice – the individual decision to come and participate – is a core attribute of respites, she says.

The respite stopped the van drop-offs, won a local zoning dispute, and has blended into the neighborhood ever since. Visits by police or emergency vehicles rarely occur there or at any respite, Hayes says.

When the Stepping Stone program opened as the nation’s first peer respite center in 1997, it was completely outside of the traditional mental health system. Today, as peer specialists get hired as part of interdisciplinary mental health teams, Stepping Stone Co-founder Shery Mead worries that the model could be co-opted by clinical programs hiring peers and calling themselves respites. But Sally Zinman, a longtime advocate and executive director of the California Association of Mental Health Peer Run Organizations, remains optimistic. “I would like to think the alternative changes the system more,” she says.

Such philosophical conversations don’t arise at the Carterville house, where day visitors and respite guests can choose to share feelings – or keep to themselves. When Ryan Plott settled into his respite stay, guests and staff were playing cards in the kitchen. “This is the best day I’ve had in weeks,” he said. “I can’t believe it exists. Whoever had this idea was a genius.”