There isn’t one definitive way to explain what a crisis is. It is probably best described by the person themselves, according to their experiences and values (Ball et al., 2005). Some people may relate their crisis to a psychiatric condition, others may see crises happening when their usual ways of coping don’t work, unrelated to psychiatric conditions. The variation in how people perceive crises explains why a ‘one size fits all’ crisis service is unlikely to meet everyone’s needs or preferences (Rojas-García et al., 2023).
Crisis Resolution Teams (CRTs) provide services that reduce the need for hospital admission for many people but have been criticised for having too high a threshold for access. Psychiatric liaison services, based in emergency departments (called ED or A&E), provide crisis care, but EDs can be extremely busy, noisy places, risking further distress. Some people simply don’t like the clinical approach that CRTs and ED provide.
Previous blogs here have described an array of research on crisis services including intensive home treatment and crisis resolution teams and acute day hospitals, while Current UK government policies call for a range of crisis services including alternatives to mainstream provision.
One such form of alternative provision that has become increasingly common is the Crisis Café. These are local, accessible, comfortable and welcoming spaces run by voluntary organisations, the NHS or a partnership between both. Staff are mostly ‘non-professional’ in that they are more typically peer supporters, volunteers or other non-clinical support workers. Cafés are designed to provide early intervention to prevent further escalation of crises and tend to be open to anyone experiencing distress, regardless of diagnosis or presenting issues.
To fill a considerable gap in the published evidence about the work of these crisis cafés, this exploratory study aimed to assess what crisis café do and what is needed to set one up in England.
One novel approach to crisis care is a Crisis Café where the focus is on creating an accessible, comfortable welcoming space.
Methods
The study team included academics, professionals and people with lived experience. A service evaluation collected qualitative data from individual videocall interviews with twelve crisis café managers who consented to take part from across England. Participants were purposively selected to include crisis cafés currently operating:
- in urban and rural settings,
- run by different organisations (NHS, voluntary organisations or both),
- with different lengths of time in operation.
A topic guide included questions about the crisis cafés, barriers and facilitators to their implementation, effectiveness and accessibility. Interviews were recorded, transcribed and anonymised before being analysed using a six-step qualitative analysis (Braun & Clarke, 2006) to identify codes and organise the codes into themes.
Results
Analysis included data from 12 interview transcripts: six interviews from an earlier qualitative study and six new interviews. Participating crisis cafés were in England, run by the voluntary sector (n=8), the NHS (n=2) and jointly (n=2). Half were in rural and half in urban settings. The earliest crisis café opened in 2014 and the most recent in 2020. The analysis resulted in 12 themes illustrated with participant quotes and presented within three broad domains (Box 1).
Box 1: Results of the thematic analysis.
The first domain identified five core roles for crisis cafés:
- Crisis cafés open every day, mostly ‘out of hours’ in the evening and at night.
- Central to their role is the availability of someone to talk to in a safe and comfortable environment.
- This includes peer support to provide a non-judgemental, listening service, signposting to other services or sometimes through providing support to access CRT or ED.
- Interventions include crisis planning and supporting people with coping skills to prevent future crises.
- In response to high thresholds for access to CRTs, crisis cafés provide support for ‘lower level’ crises, not provided for by other crisis services, particularly when medical intervention is not needed.
The second domain identified four factors that influence the effectiveness of crisis cafés.
- Fundamental to the success of crisis cafés was the belief that crises are ‘self-defined’ rather than using clinical definitions.
- Ongoing co-production was key to developing personalised care.
- Flexibility and an open-door policy, rather than aiming to meet stringent targets, marks out the crisis cafés as different.
- However, the open-door policy can make it difficult to estimate the number of staff needed.
Staff have a range of skills; many have lived experience. Training is provided and supervision supports staff to respond to distress, deal with their own feelings, and reduce the risk of becoming distressed themselves. Fostering connections with other crisis care agencies helps to prevent people ‘slipping through cracks’ between services. Some people are under-represented among visitors to crisis cafés, considered to be related to stigma and cultural barriers. Travel and safety present barriers to access, often due to out-of-hours opening. Solutions included increased use of telephone contact.
The third domain identified three key dilemmas for crisis cafés to consider. These dilemmas all relate to sustaining a different identity and purpose from more mainstream and clinical crisis services.
- An open-door makes the café accessible but creates difficulties in managing demand. Tensions arise when crisis cafés adopt systems associated with clinical services to manage demand such as asking people to wait or having an appointment system.
- Similar tensions arise in relation to triage and risk assessments. Using these approaches may assure safety and appropriate signposting but may alienate some people by increasing fears about Mental Health Act detention.
- Tensions about the crisis café’s duty of care relate to the scope of the café’s responsibility beyond the time the person is present in the café.
Fundamental to the success of crisis cafés was that mental health crises were believed to be ‘self-defined’ rather than defined by clinical labels or strict access criteria.
Conclusions
The study identified a core set of aims for crisis cafés from the perspectives of café managers in England. Factors influencing the effectiveness of crisis cafés had similarities to other types of crisis care and included accessibility, ability to deliver person centred care, staffing and connectedness with other crisis services.
Key challenges faced by crisis cafés included sustaining open-door access whilst being adequately staffed to meet demand, maintaining safety yet avoiding adopting overly clinical processes, such as risk assessment and stringent eligibility criteria. Links with other crisis services were key to avoiding people falling through cracks between services.
Strengths and limitations
This is the first study to explore the core functions and implementation of the crisis café model in-depth. The focus on implementation and service delivery lent itself to interviews with service managers who have a detailed knowledge of the day-to-day running of services and the challenges faced. Despite this, the perspective of managers is a limited one. A sample that included people visiting and working in crisis cafés could have yielded even richer data and rested more comfortably with the core ethos of crisis cafés (Dalton-Locke et al., 2021). It was good to read that the team conducting the research included a lived experience researcher and early career researchers supported by senior academics who were all involved in the collection and coding of the data, and all are named authors.
By sampling successful crisis cafés , the study missed opportunities to learn about crisis cafés that have not been sustained. Understanding the barriers to sustaining crisis services is critical to their implementation especially given what is already known about the too often precarious funding of voluntary sector crisis services (Newbigging et al., 2020).
The inclusion of data from a previous study alongside new data requires clarity on the contextual differences between the two data sets. It raised methodological questions about whether the aims of the two studies aligned or if there were any challenges in the analysis caused by having two sets of data.
The organisation of the findings into three ‘domains’ deviated from the more usual themes and sub-themes used to describe qualitative findings (Braun & Clarke, 2006). The content of the ‘domains’ and ‘themes’ is presented coherently however and is supported by quotes from participants. Despite some minor limitations, the study findings provide insights into the role, implementation, and challenges faced by crisis cafés.
Implications for practice
The findings from this study add a more detailed insight about the role of crisis cafés from the specific perspective of managers. To have an impact on practice, further research is needed to understand the perspective of those visiting and working in crisis cafés. It is particularly important to align future research with the co-production ethos underpinning the crisis café model. This would also provide insights into the impact of the challenges managers identified around staffing and safety, as these directly impact those working in and visiting crisis cafés. Such research could also explore in more depth the individual outcomes related to the ‘non-clinical’ identity of crisis cafés.
It is also important, from an implementation perspective, to understand detail about how the crisis café model works within a multi-agency crisis services system. The findings here emphasise the importance of sustained relationships between crisis cafés and other crisis services, but this is not always straightforward in a complex and constantly evolving crisis care system (Clibbens et al., 2023; Rojas-García et al., 2023).
Crisis cafés may also be particularly susceptible to funding difficulties. While their unique ‘non-clinical’ ethos is valued by many people in crisis, it simultaneously makes their sustainability vulnerable, given the degree of separation this encourages from mainstream health and care systems (Newbigging et al., 2020).
From our experiences of crisis cafés, there are some important considerations for how they are integrated with the wider crisis care system. Referral between crisis cafés and other services is not always straightforward. An example of this is people who are distressed, yet new to mental health services, being ‘signposted’ rather than referred to crisis cafés, when they don’t meet criteria for CRTs. It is easy to see how people in crisis who are less experienced in navigating complex health and care systems could easily fall between the cracks. Further, some crisis cafés are unable to provide support to people already being treated by primary or secondary mental health services yet having simultaneous support from a crisis alternative, like a café, may meet their needs more holistically.
People experiencing a crisis, and the wider crisis services staff often don’t know about crisis cafés in their area or what they provide. This resonates with the findings here where voluntary sector services manage a balancing act between visibility in their communities and vulnerability from stigma (Newbigging et al., 2020).
The study identified that stigma may create barriers to access for some people, particularly those who may be marginalised due to their living situation, poverty, health condition, culture or ethnicity. Our experience suggests that ongoing improvement and consideration of ways that crisis cafés can better support and improve access for marginalised people, including homeless people, people from different cultural or ethnic backgrounds or those who don’t trust mental health services, due to previous poor experiences or trauma, is critically important.
People running crisis cafés manage a balancing act between visibility in their communities and vulnerability from stigma
Links
Primary paper
Staples, H. Cardorna, G. Nyikavaranda, P. Maconick, L. Lloyd-Evans, B. & Johnson, S. (2024) A qualitative investigation of crisis cafés in England: their role, implementation, and accessibility, BMC Health Services Research, 24(1). https://dx.doi.org/10.1186/s12913-024-11662-0
Other references
Ball, J. S., Links, P. S., Strike, C., & Boydell, K. M. (2005). “It’s overwhelming… everything seems to be too much:” A theory of crisis for individuals with severe persistent mental illness. Psychiatr Rehabil J, 29(1), 10-17. https://doi.org/10.2975/29.2005.10.17
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. https://doi.org/doi: 10.1191/1478088706qp063oa., 200
Clibbens, N., Booth, A., Sharda, L., Baker, J., Thompson, J., Ashman, M., Berzins, K., Weich, S., & Kendal, S. (2023). Explaining context, mechanism and outcome in adult community mental health crisis care: A realist evidence synthesis. International Journal of Mental Health Nursing, 32(6), 1636-1653. https://doi.org/10.1111/inm.13204
Dalton-Locke, C., Johnson, S., Harju-Seppänen, J., Lyons, N., Rains, L. S., Stuart, R., Campbell, A., Clark, J., Clifford, A., Courtney, L., Dare, C., Kathleen, K., Lynch, C., McCrone, P., Nairi, S., Newbigging, K., Nyikavaranda, P., Osborn, D., Persaud, K., . . . Lloyd-Evans, B. (2021). Emerging models and trends in mental health crisis care in England: a national investigation of crisis care systems. medRxiv, 2021.2007.2008.21259617. https://doi.org/10.1101/2021.07.08.21259617
Newbigging, K., Rees, J., Ince, R., Mohan, J., Joseph, D., Ashman, M., Norden, B., Dare, C., Bourke, S., & 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. https://doi.org/10.3310/hsdr08290
Rojas-García, A., Dalton-Locke, C., Sheridan Rains, L., Dare, C., Ginestet, C., Foye, U., Kelly, K., Landau, S., Lynch, C., McCrone, P., Nairi, S., Newbigging, K., Nyikavaranda, P., Osborn, D., Persaud, K., Sevdalis, N., Stefan, M., Stuart, R., Simpson, A., . . . Lloyd-Evans, B. (2023). Investigating the association between characteristics of local crisis care systems and service use in an English national survey. BJPsych Open, 9(6). https://doi.org/10.1192/bjo.2023.595
