PRACTICE GUIDELINES: PRACTICE GUIDELINES:

CORE ELEMENTS IN

RESPONDING TO

MENTAL HEALTH CRISES

CORE ELEMENTS IN 


RESPONDING TO 


MENTAL HEALTH CRISES
 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Mental Health Services 

www.samhsa.gov 
PRACTICE GUIDELINES:
 


CORE ELEMENTS FOR 
 

RESPONDING TO 
 

MENTAL HEALTH CRISES
 


U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
 


Substance Abuse and Mental Health Services Administration



Center for Mental Health Services



www.samhsa.gov
 

Acknowledgements 

The publication was prepared for the Substance Abuse and Mental Health Services 

Administration (SAMHSA), U.S. Department of Health and Human Services (HHS), under 

Contract No. 208-02-0405, by Robert Bernstein, PhD, executive director of the Judge David 

L. Bazelon Center for Mental Health Law. Paolo del Vecchio served as the Government 

Project Officer. 

disclAimer 

The views, opinions, and content of this publication do not necessarily reflect the views, 

opinions or policies of the Center for Mental Health Services (CMHS), SAMHSA, or HHS. 

Public domAin notice 

All material appearing in this document is in the public domain and may be reproduced 

without permission from SAMHSA. Citation of the source is appreciated.This publication may 

not be reproduced or distributed for a fee without specific written authorization of the Office 

of Communications, SAMHSA, HHS. 

electronic Access And coPies of PublicAtion 

This publication can be accessed electronically at www.samhsa.gov. For additional free copies 

of this publication, call SAMHSA’s Health Information Network at 1-877-SAMHSA-7 

(1-877-726-4727) (English and Español). 

recommended citAtion 

Practice Guidelines: Core Elements for Responding to Mental Health Crises. HHS Pub. No. 

SMA-09-4427. Rockville, MD: Center for Mental Health Services, Substance Abuse and 

Mental Health Services Administration, 2009. 

originAting office 

Office of Consumer Affairs, Center for Mental Health Services, Substance Abuse 

and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857. 

HHS Publication No. SMA-09-4427 

Printed 2009 
Contents
 
 

I. Introduction ................................................................................................................. 1



What it Means to be in a Mental Health Crisis .......................................................... 3



The Need for Crisis Standards ................................................................................... 3



II. Responding to a Mental Health Crisis ......................................................................... 5



Ten Essential Values .................................................................................................... 5



Principles for Enacting the Essential Values ................................................................. 7



III. Infrastructure ............................................................................................................ 13



IV. Making it Happen .................................................................................................... 15



V. References ................................................................................................................. 17



iii 
Practice Guidelines: Core Elements for Responding to Mental Health Crises 
 

 

 

 

 

	 

	 

	 

	 

	 

	 

	 

	 

	 

	 

I. IntroduCtIon 

CrIses have a profound ImpaCt on people wIth 

serIous mental health or emotIonal problems. 

Adults, children and older adults with a serious mental illness or emotional disorder 

often lead lives characterized by recurrent, significant crises.These crises are not the 

inevitable consequences of mental disability, but rather represent the combined impact of a 

host of additional factors, including lack of access to essential services and supports, poverty, 

unstable housing, coexisting substance use, other health problems, discrimination and 

victimization. 

Homelessness, police contact, institutionalization and other adverse events are in 

themselves crises, and may also contribute to further crises.The statistics below paint a 

sobering picture of how crises affect the lives of people who have mental or emotional 

disabilities: 

•	 From one third to one half of homeless people have a severe psychiatric disorder.1 

•	 Approximately 7 percent of all police contacts in urban settings involve a person 


believed to have a mental illness.2 


•	 The likelihood of mental illness among people confined in state prisons and local 


jails is three to four times higher than in the general population3

 and, compared 


with other inmates, it is at least twice as likely that these individuals will be injured 


during their incarceration.4 


•	 About 6 percent of all hospital emergency department visits reflect mental health 


emergencies.5 


•	 Due to a lack of available alternatives, 79 percent of hospital emergency 


departments report having to “board” psychiatric patients who are in crisis and in 


need of inpatient care, sometimes for eight hours or longer.

6 


•	 Almost one in 10 individuals discharged from a state psychiatric hospital will be 


readmitted within 30 days; more than one in five will be readmitted within 180 


days.7 


•	 About 90 percent of adult inpatients in state psychiatric hospitals report histories 


of trauma. 8 


•	 About three quarters of youth in the juvenile justice system report mental health 


problems and one in five has a serious mental disorder.9 


•	 Mothers with serious mental illnesses are more than four times as likely as other 


mothers to lose custody of their children.10 


•	 People with serious mental illnesses die, on average, 25 years earlier than the general 


population.11 


These statistics are incomplete; they reflect just a sampling of scenarios that, while 

commonplace, constitute significant life crises for individuals with serious mental illnesses. 

1 
 

Practice Guidelines: Core Elements for Responding to Mental Health Crises 

Many such individuals experience a cascade of crisis events that place them in more 

than one of these statistical groups. For instance, readmission to a psychiatric institution—a 

high probability for adults who have been discharged from a state psychiatric hospital, 

based on these data—may feature a series of crisis events for the individual: the psychiatric 

emergency itself; forcible removal from one’s home; being taken into police custody, 

handcuffed and transported in the back of a police car; evaluation in the emergency 

department of a general hospital; transfer to a psychiatric hospital; a civil commitment 

hearing; and so on.And at multiple points in this series of interventions, there is a 

likelihood that physical restraints, seclusion, involuntary medication or other coercion may 

be used. Intense feelings of disempowerment are definitional of mental health crises, yet 

as the individual becomes the subject of a “disposition” at each juncture, that person may 

experience a diminishing sense of control. 

In the wake of rare but highly publicized tragedies attributed to people with mental 

illnesses, there is often a temporary surge in political concern about mental healthcare and 

expanding crisis interventions. Sadly, the more commonplace crises endured every day 

by many thousands of adults, older adults and children with serious mental or emotional 

problems tend to generate neither media attention nor political concern. 

While no one with a mental or emotional disorder is immune from crises, people 

with what are termed serious mental illnesses—defined as schizophrenia, bipolar disorder 

and major depression—may be most reliant on public systems. They also may be at great 

risk of recurrent crises and interventions that exacerbate their clinical and social problems. 

These guidelines focus most specifically on individuals with serious mental or emotional 

problems who tend to encounter an assortment of governmental or publicly funded 

interveners when they are in crisis. Nevertheless, the values, principles and strategies 

embedded in the guidelines that follow are applicable to all individuals with mental 

healthcare needs, across populations and service settings. 

Individuals whose diagnoses do not fit “serious mental illnesses” may be vulnerable 

to serious mental health crises that can have devastating outcomes. Interventions on their 

behalf are more likely to occur within the private healthcare sector, which mirrors public 

mental health systems’ problems in providing early and meaningful access to help.Within 

these parallel systems, crisis services are provided in a broad array of settings that ultimately 

will require translation of the guidelines presented here into specific protocols that break 

cycles of crises and advance the prospects of recovery for people with mental illnesses. 

2 
 

	 

	 

	 

	 

	 

	 

	 

what It means to be In a mental health CrIsIs 

Too often, public systems respond as if a mental health crisis and danger to self or others 

were one and the same. In fact, danger to self or others derives from common legal language 

defining when involuntary psychiatric hospitalization may occur—at best, this is a blunt 

measure of an extreme emergency.A narrow focus on dangerousness is not a valid 

approach to addressing a mental health crisis.To identify crises accurately requires a much 

more nuanced understanding and a perspective that looks beyond whether an individual is 

dangerous or immediate psychiatric hospitalization is indicated. 

While behaviors that represent an imminent danger certainly indicate the need for 

some sort of an emergency response, these behaviors may well be the culmination of a 

crisis episode, rather than the episode in its entirety. Situations involving mental health 

crises may follow trajectories that include intense feelings of personal distress (e.g., anxiety, 

depression, anger, panic, hopelessness), obvious changes in functioning (e.g., neglect of 

personal hygiene, unusual behavior) or catastrophic life events (e.g., disruptions in personal 

relationships, support systems or living arrangements; loss of autonomy or parental rights; 

victimization or natural disasters). 

Because only a portion of real-life crises may actually result in serious harm to self or 

others, a response that is activated only when physical safety becomes an issue is often too 

little, too late or no help at all in addressing the root of the crisis.And a response that does 

not meaningfully address the actual issues underlying a crisis may do more harm than good. 

the need for CrIsIs standards 

Individuals experiencing mental health crises may encounter an array of professionals 

and non-professionals trying to intervene and help: family members, peers, healthcare 

personnel, police, advocates, clergy, educators and others.The specific crisis response 

offered is influenced by a number of variables, among them: 

•	 where the intervention occurs, 

•	 at what time of day it occurs, 

•	 when it occurs within the course of the crisis episode, 

•	 the familiarity of the intervener with the individual or with the type of problem 

experienced by the individual, 

•	 interveners’ training relating to crisis services, 

•	 resources of the mental health system and the ready availability of services and 

supports, and 

•	 professional, organizational or legal norms that define the nature of the encounter 

and the assistance offered. 

3 
 

Practice Guidelines: Core Elements for Responding to Mental Health Crises 

The guidelines presented here define appropriate responses to mental health crises 

across these variables.They were developed by a diverse expert panel (see below) that 

includes individuals with and without serious mental illnesses who are leaders within 

mental health professions and mental health advocacy. 

the exPert PAnel 

robert bernstein, Ph.d. 

Bazelon Center for Mental Health Law 

Andrew bridge, J.d. 

Jonathan delman, d.sc. (cand.) 

Consumer Quality Initiatives 

Paolo del vecchio, m.s.w. 

SAMHSA 

daniel fisher, m.d., Ph.d. 

National Empowerment Center 

risa fox, m.s.w. SAMHSA 

kevin huckshorn, m.s.n. 

National Association of State Mental 

Health Program Directors 

william hudock, m.A. 

SAMHSA 

J. rock Johnson, J.d. 

Advocate 

rachel e.kaul,lcsw,cts 

SAMHSA 

franklin kim, Ph.d. National Asian American Pacific 

James mcnulty 

The STAR Center 

steven miccio 

PEOPLE, Inc. 

Paul schyve, m.d. 

The Joint Commission 

wesley sowers, m.d. 

American Association of Community Psychiatrists

susan stefan, J.d. 

Center for Public Representation 

clarence sundram, J.d. 

Islander Mental Health Association 

kenneth thompson, m.d. 

SAMHSA 

cynthia wainscott 

Mental Health America 

reviewers 

Paul s. Appelbaum, m.d. 

Columbia University 

mary blake 

SAMHSA 

Patricia deegan, Ph.d. 

Pat Deegan, Ph.D. & Associates 

Anita everett, m.d. 

Johns Hopkins School of Medicine 

howard goldman,m.d., Ph.d. 

University of Maryland 

richard mckeon, Ph.d. 

SAMHSA 

henry J. steadman, Ph.d. 

Policy Research Associates, Inc. 

marvin swartz, m.d. 

Duke University 

This report of the panel’s findings is not intended to be an exhaustive resource on 

crisis services and best practices, but rather an explanation of factors essential to any 

response to mental health emergencies. In organizations that may already have protocols for 

responding to individuals in mental health crises (for instance, police departments, hospitals 

and mental health clinics), these guidelines offer an opportunity to assess the adequacy of 

current practices based on a set of underlying values and principles. In foster care, schools 

or other settings where protocols may not currently exist, the guidelines can serve as a 

framework for examining current activities and the need for more explicit standards. In 

either instance, these crisis guidelines promote two essential goals: 

1. Ensuring that mental health crisis interventions are guided by standards consistent 

with recovery and resilience and 

2. Replacing today’s largely reactive and cyclical approach to mental health crises 

with one that works toward reducing the likelihood of future emergencies and 

produces better outcomes. 

4 
 

 

 

 

 

	 

II. respondIng to a mental health CrIsIs 

ten essentIal values 

Ten essential values are inherent in an appropriate crisis response, regardless of the 

nature of the crisis, the situations where assistance is offered or the individuals providing 

assistance: 

1.		 Avoiding harm. Sometimes mental health crises place the safety of the person, 

the crisis responders or others in jeopardy.An appropriate response establishes 

physical safety, but it also establishes the individual’s psychological safety. For 

instance, restraints are sometimes used in situations where there is an immediate 

risk of physical harm, yet this intervention has inherent physical and psychological 

risks that can cause injury and even death. Precipitous responses to individuals in 

mental health crises—often initiated with the intention of establishing physical 

safety—sometimes result in harm to the individual. An appropriate response to mental 

health crises considers the risks and benefits attendant to interventions and whenever possible 

employs alternative approaches, such as controlling danger sufficiently to allow a period of 

“watchful waiting.” In circumstances where there is an urgent need to establish physical 

safety and few viable alternatives to address an immediate risk of significant harm to the 

individual or others, an appropriate crisis response incorporates measures to minimize the 

duration and negative impact of interventions used. 

2.		intervening in Person-centered ways. 

Mental health crises may be routine in some 

settings and, perhaps, have even come to be 

routine for some people with serious mental 

health or emotional problems. Nevertheless, 

appropriate crisis assistance avoids rote 

interventions based on diagnostic labels, 

presenting complaint or practices customary 

to a particular setting. Appropriate interventions 

seek to understand the individual, his or her unique 

circumstances and how that individual’s personal 

preferences and goals can be maximally incorporated 

in the crisis response. 

“To promote patient-centered t

care, all parties involved in 

health care for mental or substance-use conditions should 

support the decision-making 

abilities and preferences for 

treatment and recovery of persons with mental/substance 

use problems and illnesses” 

Institute of Medicine (2006) Committee on Crossing

the Quality Chasm: Adaptation to Mental Health and

Addictive Disorders, Recommendation 3-1, p. 126 

3.		 shared responsibility. An acute sense of losing control over events or feelings 

is a hallmark of mental health crises. In fact, research has shown “feeling out of 

control” to be the most common reason consumers cite for being brought in for 

psychiatric emergency care.12 An intervention that is done to the individual— 

rather than with the individual—can reinforce these feelings of helplessness. One 

of the principal rationales for person-centered plans is that shared responsibility 

promotes engagement and better outcomes.While crisis situations may present 

challenges to implementing shared, person-centered plans, ultimately an 

intervention that considers and, to the extent possible, honors an individual’s role 

in crisis resolution may hold long-term benefits. An appropriate crisis response seeks 

to assist the individual in regaining control by considering the individual an active partner 

in—rather than a passive recipient of—services. 

5 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

t

Practice Guidelines: Core Elements for Responding to Mental Health Crises 

4.		 Addressing trauma. Crises, themselves, are intrinsically traumatic and certain 

crisis interventions may have the effect of imposing further trauma—both 

physical and emotional. In addition, people with serious mental illness have a 

high probability of having been victims of abuse or neglect. It is essential that 

once physical safety has been established, harm resulting from the crisis or crisis response 

is evaluated and addressed without delay by individuals qualified to diagnose and initiate 

needed treatment.There is also a dual responsibility relating to the individual’s relevant 

trauma history and vulnerabilities associated with particular interventions; crisis responders 

should appropriately seek out and incorporate this information in their approaches, and 

individuals should take personal responsibility for making this crucial information available 

(for instance, by executing advance directives). 

5.		establishing feelings of Personal safety. An individual may experience a 

mental health crisis as a catastrophic event and, accordingly, may have an urgent 

need to feel safe.What is regarded as agitated behavior may reflect an individual’s 

attempts at self-protection, though perhaps to an unwarranted threat. Assisting the 

individual in attaining the subjective goal of personal safety requires an understanding of 

what is needed for that person to experience a sense of security (perhaps contained in a crisis 

plan or personal safety plan previously formulated by the individual) and what interventions 

increase feelings of vulnerability (for instance, confinement in a room alone). Providing such 

assistance also requires that staff be afforded time to gain an understanding of the individual’s 

needs and latitude to address these needs creatively. 

Personal safety Plan 

Some state mental health 

systems encourage consumers to complete a 

form intended to help 

staff understand an individual’s preferred ways of 

addressing emerging crises. The following is the 

introduction presented 

from Florida’s adaptation of the Massachusetts 

form; it affirms the perspective of a partnership 

between staff and the 

individual. 

“This form will allow 

you to suggest calming 

strategies IN ADVANCE 

of a crisis. It will allow 

you to list things that are 

helpful when you are 

under stress or are upset. 

It will also allow you 

to identify things that 

make you angry. Staff 

and individuals receiving 

services can enter into a 

‘partnership of safety’ using this form as a guide 

to assist in your treatment 

plan.The information is 

intended only to be helpful; it will not be used for 

any purpose other than 

to help staff understand 

how to best work with 

you to maintain your 

safety or to collect data 

to establish trends.This 

is a tool that you can 

add to at any time. Information should always 

be available from staff 

members for updates or 

discussion. Please feel free 

to ask questions.” 

Massachusetts Department of Mental

Health (1996) Task Force on the Restraint 

and Seclusion of Persons who have been 

Physically or Sexually Abused, Report and

Recommendations. 

Florida Department of Children and

Families, Form CF-MH 3124, http://www.

dcf.state.fl.us/DCFForms/Search/DCFFormSearch.aspx

6.		based on strengths. Sharing responsibility for crisis resolution means 

understanding that an individual, even while in crisis, can marshall personal 

strengths and assist in the resolution of the emergency. Individuals often understand 

the factors that precipitated a crisis as well as factors that can help ameliorate their 

impact. An appropriate crisis response seeks to identify and reinforce the resources on which 

an individual can draw, not only to recover from the crisis event, but to also help protect 

against further occurrences. 

7.		 the whole Person. For individuals who have a mental illness, the psychiatric 

label itself may shape—even dominate—decisions about which crisis interventions 

are offered and how they are made available. An individual with a serious mental 

illness who is in crisis is a whole person, whose established psychiatric disability may be 

relevant but may—or may not—be immediately paramount. That the individual may 

have multiple needs and an adequate understanding of the crisis means not being 

limited by services that are compartmentalized according to healthcare specialty. 

An individual’s emergency may reflect the interplay of psychiatric issues with 

other health factors.And while the individual is experiencing a crisis that tends 

to be addressed as a clinical phenomenon, there may also be a host of seemingly 

mundane, real-world concerns that significantly affect an individual’s response: the 

whereabouts of the person’s children, the welfare of pets, whether the house is 

locked, absence from work, and so on. 

8.		 the Person as credible source. Assertions or complaints made by individuals 

who have been diagnosed with a serious mental illness tend to be viewed 

skeptically by others. Particularly within the charged context of mental health 

6 
 

 

 

 

 

 

 

 

 

 

 

 

crises, there may be a presumption that statements made by these individuals are 

manifestations of delusional thinking. Consequently, there is a risk that legitimate 

complaints relating to such matters as medical illness, pain, abuse or victimization 

will go unheeded. Even when an individual’s assertions are not well grounded in 

reality and represent obviously delusional thoughts, the “telling of one’s story” may 

represent an important step toward crisis resolution.13 For these reasons, an appropriate response to an individual in mental health crisis is not dismissive of the person as a 

credible source of information—factual or emotional—that is important to understanding the 

person’s strengths and needs. 

9.		 recovery, resilience and natural supports. Certain settings, such as hospital 

emergency departments, may see individuals only transiently, at a point when 

they are in acute crisis and in a decidedly high-stress environment. Even when 

not occurring within hospitals, mental health emergency interventions are often 

provided in settings that are alien to the individual and the natural supports that 

may be important parts of his or her daily life. It is important not to lose sight 

of the fact that an emergency episode may be a temporary relapse and not 

definitional of the person or that individual’s broader life course. An appropriate 

crisis response contributes to the individual’s larger journey toward recovery and resilience and 

incorporates these values.Accordingly, interventions should preserve dignity, foster a sense of 

hope, and promote engagement with formal systems and informal resources. 

The National Consensus Statement on Mental 

Health Recovery identifies recovery as an individual’s journey of healing and transformation 

enabling a person with 

a mental health problem 

to live a meaningful life 

in a community of his or 

her choice while striving 

to achieve his or her full 

potential. It also cites 10 

fundamental components 

for systems: 

•	 Self-Direction

•	 Individualized and

Person-Centered 

•	 Empowerment

•	 Holistic

•	 Non-Linear

•	 Strengths-Based

•	 Peer Support

•	 Respect

•	 Responsibility

•	 Hope

US Department of Health and Human

Services, Substance Abuse and Mental 

Health Services Administration, Center for 

Mental Health Services (2004) National

Consensus Statement on Mental Health 

Recovery. For the complete report, see: 

http://mentalhealth.samhsa.gov/publications/

allpubs/sma05-4129/

t

10. Prevention. Too often, individuals with serious mental illnesses have only 

temporary respite between crises.Anappropriate crisis response works to ensure 

that crises will not be recurrent by evaluating and considering factors that 

contributed to the current episode and that will prevent future relapse. Hence, 

an adequate crisis response requires measures that address the person’s unmet needs, both 

through individualized planning and by promoting systemic improvements. 

prInCIples for enaCtIng the essentIal values 

Several principles are key to ensuring that crisis intervention practices embody these 

Essential Values: 

1.		 Access to supports and services is timely. Ready access to assistance is 

important not only because it holds the promise of reducing the intensity and 

duration of the individual’s distress, but also because as a crisis escalates, options 

for interventions may narrow.Timely access presupposes 24-hour/7-days-a-week 

availability and a capacity for outreach when an individual is unable or unwilling 

to come to a traditional service site. 

2.		 services are provided in the least restrictive manner. Least-restrictive 

emergency interventions not only avoid the use of coercion, but also preserve 

the individual’s connectedness with his or her world. Individuals should not be 

unnecessarily isolated from their routine networks of formal and natural supports 

and should be encouraged to make contact with outside professionals, family and 

friends who can provide assistance through the crisis event and beyond. 

7 
 

 

 

 

 

 

 

 

t

Practice Guidelines: Core Elements for Responding to Mental Health Crises 

3.		Peer support is available. Services should afford opportunities for contact with 

others whose personal experiences with mental illness and past mental health crises 

allow them to convey a sense of hopefulness first-hand. In addition, peers can offer 

opportunities for the individual to connect with a supportive circle of people 

who have shared experiences—an option that may have particular relevance given 

feelings of isolation and fear that may accompany a mental health crisis. 

4.		 Adequate time is spent with the individual in crisis. In settings such 

as hospital emergency departments, there may be intense pressure to move 

patients through quickly.14 People who provide assistance must have an adequate 

understanding of the crisis situation, not only objectively, but also as it is being 

experienced by the individual who is in crisis. Unfortunately, individuals in acute 

crisis—particularly following involuntary transport to an evaluation setting—may 

not be in a position to discuss their presenting complaints clearly and concisely. 

Personnel in healthcare and similar settings must regard face-to-face time with the 

individual not as a distraction, but as a core element of quality crisis care. Settings 

that cannot accommodate the individual in this way may not be appropriate 

venues for psychiatric crisis intervention; as is discussed elsewhere in these 

guidelines, such a determination should be regarded as a problem in care and drive 

performance improvement at both the organizational and systemic levels. 

staff behaviors that 

consumers feel 

Are most important 

to individuals in a 

mental health crisis 

•	 Having the staff listen

to me, my story and 

my version of events 

•	 Being asked about

what treatment I want 

•	 Trying to help me

calm down before 

resorting to forced 

treatment 

• Being asked about

what treatments were 

helpful and not helpful 

to me in the past 

Allen, M., Carpenter, D., Sheets, J, Miccio, 

S., & Ross, R. (2003) What do consumers 

say they want and need during a psychiatric

emergency? Journal of Psychiatric Practice 

(9) 1, 39-58.

5.		Plans are strengths-based. It may be fairly routine for professional staff to 

concentrate on clinical signs and other deficits to be addressed, particularly when 

an individual is in a crisis state and, therefore,“symptomatic.” Yet appropriate 

crisis intervention gives at least equal attention to the individual’s immediately 

available and potentially available assets.A strengths-based plan helps to affirm the 

individual’s role as an active partner in the resolution of the crisis by marshalling 

his or her capabilities.A strengths-based approach also furthers the goals of 

building resilience and a capability for self-managing future crises. 

6.		emergency interventions consider the context of the individual’s overall 

plan of services. Many individuals with serious mental illnesses go into mental 

health crises while receiving some sort of services and supports.Appropriate crisis 

services consider whether the crisis is, wholly or partly attributable to gaps or 

other problems in the individual’s current plan of care and provide crisis measures 

in ways that are consistent with services the individual receives (or should receive) 

in the community. In addition, appropriate crisis services place value on earlier 

efforts by the individual and his or her service providers to be prepared for 

emergencies, for instance, by having executed psychiatric advance directives or 

other crisis plans. Incorporating such measures in a crisis response requires that 

interveners be knowledgeable about these approaches, their immediate and longerterm value, and how to implement them. Appropriate crisis interventions also 

include post-event reviews that may produce information that is helpful to the 

individual and his or her customary service providers in refining ongoing services 

and crisis plans. 

8 
 

 

 

 

 

 

7.		 crisis services are provided by individuals with appropriate training and 

demonstrable competence to evaluate and effectively intervene with the 

problems being presented. Crisis intervention may be considered a high-end 

service, that is high-risk and demanding a high level of skill.Within the course of 

a psychiatric emergency, various types of crisis interventions may occur—some 

by healthcare professionals, some by peers and some by personnel (such as police) 

who are outside of healthcare.Throughout, the individual experiencing a mental 

health crisis should be assured that all interveners have an appropriate level of 

training and competence.What that means may vary considerably between 

scenarios. For instance, a significant number of instances of police involvement 

with individuals in mental health crises result in injuries or even death.15 

Accordingly, some police departments have taken special measures to train officers 

in identifying and de-escalating mental health crises. Many have also established 

links with mental health professionals who can provide timely on-site assistance. 

These efforts have required police and health care professionals to connect across 

traditional bureaucratic boundaries. 

8.		 individuals in a self-defined crisis are not turned away. People who seek 

crisis services but do not meet the service criteria of an organization should 

receive meaningful guidance and assistance in accessing alternative resources.This 

is particularly applicable in organizations or programs that carry out a screening 

or gatekeeping function. For instance, it is not sufficient, upon determining that 

an individual fails to meet the criteria for hospitalization, to tell the individual or 

family members to make contact again if the situation worsens. Such practices 

tacitly encourage the escalation of crises. Individuals and their families should 

be assisted in accessing services and supports that resolve issues early on, and an 

organization providing screening or gatekeeping services should be fluent with 

alternatives for when service thresholds are not met.When these alternatives are 

lacking, the organization should consider this a problem in care and take action 

accordingly. Likewise, an organization providing early intervention that routinely 

receives referrals from hospital gatekeepers might consider improving its outreach 

so that individuals seeking help are more likely to access their services directly, 

without placing demands on programs designed for late-stage emergencies. 

An Alternative Approach 

“The Hospital Diversion 

Program at the ROSE 

HOUSE is currently available to residents of Orange 

and Ulster counties [New 

York State]. This peer-operated house is designed 

to assist fellow peers in 

diverting from psychiatric 

distress, which may lead to 

a hospitalization.The program is located in a threebedroom home set up and 

furnished for comfort.The 

house is equipped with a 

variety of traditional selfhelp and proactive tools to 

maintain wellness. Trained 

peer companions are the 

key ingredients in helping others learn self-help 

tools. Peer companions 

are compassionate, understanding and empowering. 

We exist to fill a gap in 

the mental health system 

that can brake the cycle of 

going from home to crisis 

to hospital. 

The ROSE HOUSE offers 

a stay of up to five days to 

take control of your crisis 

or potential crisis and develop new skills to maintain your wellness. Peer 

companions staff the house 

24 hours a day to address 

the needs of guests as they 

arise. Participation in the 

program is completely voluntary and free of charge. 

You are free to come and 

go as you please. We also 

will maintain contact and 

support for you, at your 

request, after you finish 

your stay. We have found 

that occasional calls and 

visits reinforce recovery 

and self determination.” 

From the website of Projects to Empower and 

Organize the Psychiatrically Labeled (PEOPLe, 

Inc.) at: http://www.projectstoempower.org

t

9.		interveners have a comprehensive understanding of the crisis. Meaningful 

crisis response requires a thorough understanding of the issues at play.Yet, for people 

with serious mental illnesses, interventions are commonly based on a superficial set of 

facts: behaviors are seen to present a safety issue, the individual has reportedly failed 

to take medications as prescribed, or an encounter with the police has occurred. 

An appropriate understanding of the emergency situation not only includes an 

appreciation for what is happening at the moment, but also why it is happening and 

how an individual fares when he or she is not in crisis. Crises—particularly recurrent 

crises—likely signal a failure to address underlying issues appropriately. When crisis 

intervention occurs outside of the individual’s customary setting, such as in a hospital 

emergency department or a psychiatric inpatient unit, it may be challenging to gain a 

good picture of the individual’s circumstances. 

9 
 t

Practice Guidelines: Core Elements for Responding to Mental Health Crises 

Mobile outreach services, which have the capacity to evaluate and intervene 

within the individual’s natural environment, have inherent advantages over 

facility-based crisis intervention, especially when an individual who has personal 

experience with mental illness and mental health crises is a part of the intervention 

team. Such mobile outreach capacity is even more meaningful when it is not 

restricted to a special crisis team, but rather when staff and peers familiar with the 

individual have the ability to literally meet the individual where he or she is.When 

intervention within an individual’s normal living environment is not feasible, 

hospitalization is not the inevitable alternative; for many individuals facing civil 

commitment, consumer-managed crisis residential programs can represent a viable, 

more normalized alternative that produces good outcomes.16 

10. helping the individual to regain a sense of control is a priority. Regaining 

a sense of control over thoughts, feelings and events that seem to be spinning 

out of control may be paramount for an individual in mental health crisis. Staff 

interventions that occur without opportunities for the individual to understand 

what is happening and to make choices among options (including the choice to 

defer to staff) may reinforce feelings that control is being further wrested away.The 

individual’s resistance to this may be inaccurately regarded as additional evidence 

of his or her incapacity to understand the crisis situation. Incorporating personal 

choice in a crisis response requires not only appropriate training, but also a setting 

with the flexibility to allow the exercise of options. Informed decision-making in 

this context is not a matter of simply apprising the individual of the empirically 

derived risks and benefits associated with various interventions; it also includes 

an understanding among staff that an ostensibly sub-optimal intervention that is 

of the individual’s choosing may reinforce personal responsibility, capability and 

engagement and can ultimately produce better outcomes.The specific choices 

to be considered are not limited to the use of medications, but also include the 

individual’s preferences for what other approaches are to be used where crisis 

assistance takes place, involving whom and with what specific goals.While the 

urgency of a situation may limit the options available, such limitations may also 

highlight how earlier interventions failed to expand opportunities to exercise 

personal control. Post-crisis recovery plans or advance directives developed 

by the individual with assistance from crisis experts are important vehicles for 

operationalizing this principle. 

national resource 

center on Psychiatric 

Advance directives 

Psychiatric advance 

directives (PADs) are 

relatively new legal 

instruments that may 

be used to document 

a competent person’s 

specific instructions or 

preferences regarding 

future mental health 

treatment, in preparation 

for the possibility that 

the person may lose 

capacity to give or 

withhold informed 

consent to treatment 

during acute episodes 

of psychiatric illness. 

Almost all states permit 

some form of legal 

advance directive (AD) 

for healthcare, which 

can be used to direct 

at least some forms of 

psychiatric treatment. 

In the past decade, 25 

states have adopted 

specific PAD statutes. 

http://www.nrc-pad.org 

11. services are congruent with the culture, gender, race, age, sexual 

orientation, health literacy and communication needs of the individual 

being served. Given the importance of understanding how an individual is 

experiencing a crisis and engaging that individual in the resolution process, 

being able to effectively connect with the individual is crucial.A host of variables 

reflecting the person’s identity and means of communicating can impede 

meaningful engagement at a time when there may be some urgency. Establishing 

congruence requires more than linguistic proficiency or staff training in cultural 

sensitivity; it may require that to the extent feasible, an individual be afforded a 

choice among staff providing crisis services. 

10 
 

 

 

 

 

12. rights are respected. An individual who is in crisis is also in a state of 

heightened vulnerability. It is imperative that those responding to the crisis be 

versed in the individual’s rights, among them: the right to confidentiality, the 

right to legal counsel, the right to be free from unwarranted seclusion or restraint, 

the right to leave, the right for a minor to receive services without parental 

notification, the right to have one’s advance directive considered, the right to speak 

with an ombudsman and the right to make informed decisions about medication. 

It is critical that appropriately trained advocates be available to provide needed 

assistance. Correctly or not, many individuals with serious mental illnesses have 

come to regard mental health crisis interventions as episodes where they have 

no voice and their rights are trampled or ignored. Meaningfully enacting values 

of shared responsibility and recovery requires that the individual have a clear 

understanding of his or her rights and access to the services of an advocate. It is 

also critical that crisis responders not convey the impression that an individual’s 

exercise of rights is a hostile or defiant act. 

13. services are trauma-informed. Adults, children and older adults with serious 

mental or emotional problems often have histories of victimization, abuse and 

neglect, or significant traumatic experiences.Their past trauma may be in some 

ways similar to the mental health crisis being addressed. It is essential that crisis 

responses evaluate an individual’s trauma history and the person’s status with 

respect to recovery from those experiences. Similarly, it is critical to understand 

how the individual’s response within the current crisis may reflect past traumatic 

reactions and what interventions may pose particular risks to that individual 

based on that history. Because of the nature of trauma, appropriately evaluating an 

individual requires far more sensitivity and expertise than simply asking a series of 

blunt, potentially embarrassing questions about abuse and checking off some boxes 

on a form. It requires establishing a safe atmosphere for the individual to discuss 

these issues and to explore their possible relationship to the crisis event. 

“Confounding and complicating the prevalence 

of trauma in public 

mental health service 

recipients is the fact that 

mental health services 

themselves are often experienced as traumatic. 

The use of coercive interventions such as seclusion and restraint, forced 

involuntary medication 

practices, and philosophies of care based on 

control and containment 

vs. empowerment and 

choice often cause unintentional re-traumatization in already vulnerable 

populations.” 

National Association of State Mental Health 

Program Directors (2005) NASMHPD

Position Statement on Services and Supports

to Trauma Survivors 

t

14. recurring crises signal problems in assessment or care. Many 

organizations providing crisis services—including emergency departments, 

psychiatric hospitals and police—are familiar with certain individuals who 

experience recurrent crises.They have come to be regarded as “high-end users.” 

In some settings, processing these individuals through repeated admissions within 

relatively short periods of time becomes so routine that full reassessments are 

not conducted; rather, clinical evaluations simply refer back to assessments and 

interventions that were conducted in previous (unsuccessful) episodes of care. 

While staff sometimes assume that these scenarios reflect a patient’s lack of 

understanding or willful failure to comply with treatment, recurrent crises are 

more appropriately regarded as a failure in the partnership to achieve the desired 

outcomes of care.And rather than reverting to expedient clinical evaluations and 

treatment planning that will likely repeat the failed outcomes of the past, recurrent 

crises should signal a need for a fresh and careful reappraisal of approaches, 

including engagement with the individual and his or her support network. 

11 
Practice Guidelines: Core Elements for Responding to Mental Health Crises 

15. meaningful measures are taken to reduce the likelihood of future 

emergencies. Considering the deleterious impact of recurrent crises on the 

individual, interventions must focus on lowering the risk of future episodes. Crisis 

intervention must be more than another installment in an ongoing traumatic cycle. 

Meaningfully improving an individual’s prospects for success requires not only 

good crisis services and good discharge planning, but also an understanding that 

the crisis intervener—be it police, hospital emergency department, community 

mental health program, or protective service agency—is part of a much larger 

system. Performance-improvement activities that are confined to activities within 

the walls of a single facility or a specific program are sharply limited if they do 

not also identify external gaps in services and supports that caused an individual 

to come into crisis.Although addressing certain unmet needs may be beyond the 

purview of one facility or program, capturing and transmitting information about 

unmet needs to entities that have responsibility and authority (e.g., state mental 

health programs, housing authorities, foster care and school systems) is an essential 

component of crisis services. 

t

“Most performance 

measurement efforts 

tend to operate in isolation from one another 

to meet the specific 

needs of their sponsors. 

Frequently, data collection efforts are particular to specific care 

settings—such as hospitals or ambulatory care 

organizations—or to

particular payers, whether private or public... 

Since data are collected 

and used in fragmented 

ways, they rarely provide 

a picture of the overall 

quality of performance 

for a specific clinician 

or organization, or how

well patients fare, or 

the state of the public’s 

health at large.” 

Health Care at the Crossroads: Development of a National Performance Measurement Data Strategy. The Joint Commission, 

2008, p.8.

12 

 

	 

	 

	 

	 

	 

	 

	 

	 

III. InfrastruCture
 An organization’s infrastructure should support interventions consistent with the values 

and principles listed above. Given the nature of crises affecting individuals with serious 

mental or emotional problems, these values and principles are applicable to a very broad 

array of organizations—hospital emergency departments, psychiatric programs, foster care, 

education, police, schools, and courts.While needed infrastructure will necessarily vary 

by setting, population served and the acuteness of crises being addressed, there are some 

important common denominators: 

•	 staff that is appropriately trained and that has demonstrated competence 

in understanding the population of individuals served, including not only a clinical 

perspective, but also their lived experiences. 

•	 staff and staff leadership that understands, accepts and promotes the 

concepts of recovery and resilience, the value of consumer partnerships and 

consumer choice, and the balance between protection from harm and personal 

dignity. 

•	 staff that has timely access to critical information, such as an individual’s 

health history, psychiatric advance directive or crisis plan. Such access is, in part, 

reliant on effective systems for the retrieval of records, whether paper or electronic. 

•	 staff that is afforded the flexibility and the resources, including the resource 

of time, to establish truly individualized person-centered plans to address the 

immediate crisis and beyond. 

•	 staff that is empowered to work in partnership with individuals being 

served and that is encouraged, with appropriate organizational oversight, to craft 

and implement novel solutions. 

•	 An organizational culture that does not isolate its programs or its staff 

from its surrounding community and from the community of individuals being 

served.This means that the organization does not limit its focus to “specific” patientlevel interventions, but also positions itself to play a meaningful role in promoting 

“indicated” strategies for the high-risk population it serves and “universal” 

strategies that target prevention within the general population.The intent here is 

not to dissipate the resources or dilute the focus of an organization, but to assure 

recognition that its services are a part of a larger spectrum and that it actively 

contributes to and benefits from overall system refinements. 

•	 coordination and collaboration with outside entities that serve as sources of 

referrals and to which the organization may make referrals. Such engagement should 

not be limited to service providers within formal networks, but should also include 

natural networks of support relevant to the individuals being served. 

•	 rigorous performance-improvement programs that use data meaningfully 

to refine individuals’ crisis care and improve program outcomes. Performance 

improvement programs should also be used to identify and address risk factors 

or unmet needs that have an impact on referrals to the organization and the 

vulnerability to continuing crises of individuals served. 

13 
Practice Guidelines: Core Elements for Responding to Mental Health Crises 

14 
 

 

 

 

 

 

 

 

 

Iv. maKIng It happen
 The need for major improvements in crisis services for adults, children and older 

adults with serious mental or emotional problems is obvious.The statistics presented in 

the introduction to these guidelines make a clear case that people with mental illnesses 

are vulnerable to repeated clinical and life crises that can have deleterious effects on the 

individual, families and social networks, and communities. Many interventions could have 

a significant, positive impact on the frequency and severity of mental health crises, but they 

are not readily available to most of the individuals who need them.17 

Properly applied, these guidelines should work to improve the quality of services for 

people who are in or are vulnerable to mental health crises. Embedded in the guidelines 

is the notion that crisis services should not exist in isolation; crises are a part of an 

individual’s life experiences and the assistance provided during crisis periods is part of a 

larger set of services and supports provided to the individual.While the values, principles 

and infrastructure recommendations presented here focus on crises affecting people with 

serious mental illnesses, they also have wider application; they reflect generally accepted 

approaches to working with individuals who have mental or emotional problems, whether 

or not they are in crisis. Stated differently, these guidelines challenge any disjuncture 

between responses to mental health crises and routine mental healthcare.They demonstrate 

how appropriate emergency mental health responses should affirm the principles of 

recovery and resilience that are the benchmarks for appropriate mental healthcare even 

though crisis scenarios may test the application of these values. 

From a practice standpoint, these guidelines may be most effectively enacted when 

they are embedded in the various quality-control and performance-improvement 

mechanisms that operate within an organization.When appropriately conducted, quality 

control and performance-improvement processes should be data-driven and attuned to 

demonstrating not only what segments of the service population are prone to mental 

health crises, but also what factors underlie their vulnerability.An adequate understanding 

of these factors requires much more than the “encounter” data now routinely collected by 

both healthcare organizations and police. Data collection should clearly reflect the premise 

that mental health crises represent problems in care (whether individual or systemic) and 

should facilitate the root-cause analyses that are required when significant problems in care 

occur. Similarly, data should be used as tools for identifying gaps, developing remedies and 

monitoring the impact of these remedies. Providers and provider organizations should have 

access to these data for purposes of ensuring the quality of care and the appropriate use of 

resources.To the extent that the causes of mental health crises extend beyond the domains 

of an emergency department, a hospital, a mental health system, a police department, and/ 

or a housing authority, data without personal identifiers should be routinely shared across 

systems. Entities having oversight responsibility should ensure that these performanceimprovement activities are being carried out and that opportunities exist for cross-agency/ 

cross-system analysis of information and the implementation of strategies to reduce mental 

health crises.And the partnerships between providers and consumers that are appropriate in 

the context of individual crises should be mirrored at the performance-improvement level. 

15 
 

Practice Guidelines: Core Elements for Responding to Mental Health Crises 

In addition to the human case for improving crisis services, a strong business case can 

be made and data should be collected accordingly. Current approaches to crisis services 

needlessly perpetuate reliance on expensive, late-stage interventions (such as hospital 

emergency departments) and on settings that have inherent risks for harm for people 

with mental health needs (for instance, jails and juvenile justice facilities). Resources and 

personnel that might otherwise be available for more effective, less risky and less expensive 

interventions are now channeled into these costly and suboptimal settings.The factors that 

sustain late-stage crisis interventions may be linked to reimbursement practices and political 

considerations, yet in some ways the service system is itself complicit. Performanceimprovement data derived from on-the-ground case experience can paint a compelling 

story of how “the right services at the right time” would look for individuals who are 

currently at high risk for future crises. These data can also set the stage for concrete 

discussions of the costs and the benefits of changes in policies governing the provision and 

funding of services and supports. 

In short, the approach to crisis services must be forward-looking rather than merely 

reactive, with success seen as the ability of the individual served to return to a stable life in 

the community. Rather than leading merely to an increase in the number of beds available 

for mental health care, it must have as its goal a reduction in the number of crises among 

people with mental illnesses and therefore a reduced need for emergency services. 

16 
 

 

v. referenCes
 
 1		 McQuistion, H.L., Finnerty, M, Hirschowitz, J, and Susser, E.S. (2003).“Challenges 

for Psychiatry in Serving Homelessness People with Psychiatric Disorders,” 

Psychiatric Services, 54, 669-676. 

2		 Deane, Martha, Steadman, Henry J., Borum, Randy,Veysey, Bonita, Morrisssey, 

Joseph P.“Emerging Partnerships Between Mental Health and Law Enforcement.” 

Psychiatric ServicesVol. 50, No. 1. January 1999: pp. 99-101. 

3		 Paula M. Ditton, Mental Health and Treatment of Inmates and Probationers, US 

Department of Justice, Bureau of Justice Statistics (Washington, DC: 1999), NCJ 

174463. 

4		 James, D. & Glaze, L. Mental Health Problems of Prison and Jail Inmates (2006). Special 

Report, Bureau of Justice Statistics. Findings based on data from interviews with 

state prisoners in 2004 and local jail inmates in 2002, http://www.ojp.usdoj.gov/bjs/ 

pub/pdf/mhppji.pdf 

5		 Larkin, G.L., Claassen, C.A., Emond J.A., et al. (2005) Trends in U.S. emergency 

department visits for mental health conditions, 1992-2001. Psychiatric Services (56) 

671-677 

6		 American College of Emergency Physicians (2008), Psychiatric and Substance Abuse 

Survey At http://www.acep.org/uploadedFiles/ACEP/Advocacy/federal_issues/ 

PsychiatricBoardingSummary.pdf 

7		 Manderscheid, Ronald and Berry, Joyce (2004). Mental Health, United States 2004. 

U.S. Department of Health and Human Services, Center for Mental Health Services 

(2004).At http://mentalhealth.samhsa.gov/publications/allpubs/sma06-4195/ 

default.asp 

8 Ibid. 

9		 Abt Associates, Inc. (1994). Conditions of confinement: Juvenile detention and corrections 

facilities. Office of Juvenile Justice and Delinquency Prevention:Washington, DC. 

10		 Nicholson, J., & Henry,A.D. (2003).Achieving the goal of evidence-based 

psychiatric rehabilitation practices for mothers with mental illnesses. Psychiatric 

Rehabilitation Journal, 27:122-130. 

11		 Parks, J., Singer P., et al (2006) Morbidity and Mortality in People with Serious Mental 

Illness, National Association of State Mental Health Program Directors,Alexandria 

12		 Allen, M, Carpenter, D., et al (2003) What do consumers say they want and need 

during a psychiatric emergency? Journal of Psychiatric Practice (9) 1, pp. 39-58. 

13 Ibid. 

14		 Stefan, S (2006) Emergency Department Treatment of the Psychiatric Patient: Policy Issues 

and Legal Requirements, Oxford University Press 

17 
 

 

 

Practice Guidelines: Core Elements for Responding to Mental Health Crises 

15		 Stefan, S.,What is the current state of the law regarding the use of police force 

against people with psychiatric disabilities? Center for Public Representation, 

http://www.centerforpublicrep.org/community-integration/use-of-force-bypolice-against-people-with-psychiatric-disabilities 

16		 Greenfield,T.K., Stoneking, B.C. et al ((2008) A randomized trial of a mental 

health consumer-managed alternative to civil commitment for acute psychiatric 

crisis. American Journal of Community Psychology (42) 1-2, pp. 135-144. 

17		 Achieving the Promise:Transforming Mental Health Care in America. Final Report. 

(DHHS Publication No. SMA 03-3832).Washington, DC: U.S. Government 

Printing Office. 

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2009 SMA-09-4427