BRIEF REPORT

The Impact of a Mental Health Crisis Respite upon Clients’Symptom Distress

Jonathan Rosen • Maria O’Connell

Received: 9 June 2011 / Accepted: 2 July 2012 / Published online: 21 July 2012

� Springer Science+Business Media, LLC 2012

Abstract This study examined clients who were admitted

to a mental health respite program in the first 3 months of

2011 in order to identify the ability of the program to reduce

symptom distress and to explore related psychosocial fac-

tors. Participants were provided with self-report question-

naires that included measurements of demographics, mental

health status, symptom severity, and program satisfaction.

Results indicate a significant improvement in symptom

distress (p \ 0.05), mental health confidence (p \ 0.1), and

self-esteem (p \ 0.05) from admission to discharge. No

change was detected in largely external measurements.

Keywords Mental health respite � Hospital diversion �Symptom distress � Community mental health

Introduction

Increasing healthcare costs remain a prominent issue, as it

possesses a significant share of the American economy

(Romano 2006). A study by Mark et al. (2003) indicates that

10 % of Medicaid spending and between 3.1 and 5.6 % of

private health insurance claims goes to mental and/or

behavioral healthcare treatment. Furthermore, not all private

insurance companies offer mental health services and those

that do are often incomplete in the services they offer (Wolff

2008). One aspect of these expenses is psychiatric admis-

sions to hospital emergency departments where clients are

typically admitted for suicidal ideation, homicidal ideation,

or is otherwise considered gravely disabled. These depart-

ments are required by law to accept patients regardless of

whether that individual possesses insurance (US House of

Representatives 1986). Among these admissions, approxi-

mately 25–30 % consist of a non-emergency nature (Cla-

assen et al. 2000), thereby adding unnecessary costs to the

emergency departments themselves.

One solution to this troubling phenomenon is the

implementation of crisis stabilization services within the

community. Originally conceived in the 1970s (McCord

and Packwood 1973) crisis programs can now be found

throughout the country and even internationally (Memphis

Opens… 2009; Glover et al. 2006; Lyons et al. 2009).

Many operate in at least some capacity for 24 h a day,

7 days a week (Glover et al. 2006) through both hotlines

(Adams and El-Mallakh 2009) and mobile crisis teams

(Johnson et al. 2005).

Some crisis units also offer short-term psychiatric crisis

stabilization housing—programs known as respite (Adams

and El-Mallakh 2009; Sledge et al. 1996; Davidson et al.

1996)—to offer care for the ‘‘most critically ill patients’’

(Wolff 2008). Adams and El-Mallakh (2009) describe their

program in the following way: ‘‘The [program] is a non-

locked facility. Staff includes a psychiatrist, licensed clinical

social workers, art therapists, and peer support counselors.

At least two staff members are on site 24 [hours] per day.

Visitors are permitted and a separate phone line is available

for patients’’ (page 397). Respite is not exclusive to crisis

programs, however, and some focus on specific client pop-

ulations (Chou et al. 2008; Briggs et al. 2007).

The respite program from the Adams and El-Mallakh

study (2009) most closely resembles the program of focus

J. Rosen (&)

Department of Social Work, Southern Connecticut State

University, New Haven, CT, USA

e-mail: jonathan.m.rosen@gmail.com

M. O’Connell

Department of Psychiatry, Yale School of Medicine,

New Haven, CT, USA

e-mail: maria.oconnell@yale.edu

123

Community Ment Health J (2013) 49:433–437

DOI 10.1007/s10597-012-9523-0

for this study both structurally—such as integration within

a larger crisis program and program staffing—as well as a

focus on mental health crisis. Among the participants,

(66 %) were female, the average age was 34 years old, and

a great majority (79 %) of clients was diagnosed with

severe and persistent mental illness. Their study utilized

two mental health screening tools as part of the program’s

standard policy for both admission and discharge. The first

measure, the Brief Psychiatric Rating Scale (BPRS), is

used to measure psychiatric symptom severity, whereas the

Beck Depression Inventory specifically measures depres-

sive severity. Results from this study indicated not only

high patient satisfaction but also a significant reduction in

‘‘a wide range of psychiatric symptoms’’. This study shows

clear results for its target population but notes that it is also

‘‘the first systematic data for this form of hospital diversion

care.’’ Further research into this specific type of respite

program is therefore needed to enhance the current litera-

ture and define effective qualities of their structures.

Sledge et al. (1996) looked at the clinical outcomes of

another respite program in New Haven Connecticut. Unlike

the Adams and El-Mallakh program this respite was not

directly associated with a crisis unit but is otherwise

structurally similar; including around the clock staffing,

similar length of stay, and that clients are encouraged to

maintain their daily routine (Sledge et al. 1996; Davidson

et al. 1996). This facility was also associated with a day

hospital program to provide clients with treatment during

the day. Such a design allows for clients to stay at respite

during the evening yet attend mental health/substance

abuse treatment during the day. The authors from the

Sledge et al. (1996) study cite this fact to be a particular

strength because it allows ‘‘the flexibility to separate the

residential portion of treatment from the ongoing medical/

psychiatric and the rehabilitative elements of an intensive

treatment approach’’ (page 1067). They found insignificant

differences between both programs regarding improvement

of client symptoms and quality of life—indicating that both

the inpatient and crisis programs were similarly effective.

Effectiveness of Respite

Despite the age of some of these programs (the program

this study looks at has been around for close to 20 years

and the program from Adams and El-Mallakh (2009) for

about 10) there have been few studies to look at the

effectiveness of the respite program itself (Adams and El-

Mallakh 2009). Evidence has already indicated that the

implementations of crisis programs have had a noticeably

positive effect of reducing hospital admissions (Glover

et al. 2006; Jethwa et al. 2007; Phillips et al. 2001). Due to

stigmatization of an inpatient psychiatric stay, admission to

a respite unit has also been found to be less threatening

(Sledge et al. 1996). Other aspects of certain programs

have also indicated greater progress in treatment, such as

attendance to community meetings (Rogers et al. 1993).

This study specifically looked at the respite program as

implemented by the Crisis Stabilization and Prevention

(CSP) program in a private, non-profit, grant-funded, lead

mental health authority (LMHA) in Meriden, Connecticut.

This respite is integrated within CSP and is staffed by 2

mental health workers 24 h a day, 7 days a week. The unit is

able to accommodate 10 clients and provides meals, snacks,

and linens to use during their stay. Requirement for admis-

sion are that an individual must (a) be receiving treatment (at

the parent LMHA or elsewhere) for a psychiatric diagnosis

and (b) will consent to sobriety from drugs and alcohol while

in the program. The program itself is voluntary and clients

self-administer any medications under staff supervision.

Mental and physical health treatment is not provided by

respite staff, although all staff are qualified to provide psy-

chosocial support to clients. In fact, staff are instructed to

engage with clients in order to assess for safety (suicidality

and homicidality) as well as emotional, behavioral, and

physical needs. Staff then work with clients by addressing

and supplementing these needs in the form of dialog or

social/recreational activities. Referrals to the program are

made through the CSP’s mobile crisis team, outpatient

clinics, and local hospitals. Although there are many studies

that look at crisis programs and population-specific respite

programs, little research looks at broader psychiatric stabil-

ization respite programs such as the one used in this study.

Purpose of the Study

It was hypothesized that a client’s participation in the

respite program would have a positive impact upon the

stabilization of the individual’s crisis as identified by a

significant improvement in symptom distress.

Methods

Sample

The sampling pool for the study consisted of all clients

admitted to Respite between January and March 2011

(approximately 22) who consented to participate (n = 14).

Every client admitted to the program during the studied

period was approached and offered to participate. Approxi-

mately four individuals declined participation and 18 con-

sented to participate in the study, of whom four left the

program prior to full completion leaving the total sample size

for the analyses at 14 individuals. Participants were pre-

dominantly single (79 %), white/Caucasian (50 %), and

female (64 %). Every participant reported to be between 26

434 Community Ment Health J (2013) 49:433–437

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and 65 years of age, and was evenly distributed between the

26–35, 36–45, and 46–55 ranges (each held 29 % of partic-

ipants), although fewer were in the 56–65 range (14 %).

Instruments

Instruments used in this study were an Entrance and Exit

Questionnaire. Both forms were identical with the excep-

tions that the Entrance Questionnaire included demo-

graphic questions (such as: age, gender, and ethnic

background) whereas the Exit Questionnaire did not.

Additionally, the Exit Questionnaire included the Con-

sumer Satisfaction Survey (Nguyen et al. 1983), whereas

the Entrance Questionnaire did not.

Both questionnaires also contained a measure of Daily

Activities and Functioning (DAF). The DAF is a 13 item

instrument designed by the authors to assess participant

engagement in various daily activities. Questions include

‘Did you’: ‘Go for a walk’, and ‘Go shopping’ and

responders are asked to answer with either a ‘yes’ or ‘no’.

The remainder of both forms included a series of stan-

dardized measures. The Quality of Life scale (QOL) is a

single, generalized question designed to assess ones satis-

faction with various life domains and level of functioning

(Lehman 1988). The Mental Health Confidence scale

(MHC) consists of 16 items that examine self-reported self-

efficacy and confidence experienced in the lives of indi-

viduals with mental illness (Carpinello et al. 2000). The

Rosenberg Self-Esteem Scale (RSE) has shown good reli-

ability and validity in its ability to measure an individual’s

positive and negative self-esteem (Rosenberg 1979).

The Social Support Questionnaire (SSQ) is an instru-

ment that measures an individual’s social support on three

qualities: instrumental, affirmative, and affective (Norbeck

et al. 1981, 1983; Byers and Mullis 1987). The Symptom

Distress Scale (SDS) is a self-report measure that rates

psychiatric symptom severity by utilizing a number of

questions focused on whether the client is experiencing:

‘nervousness or shakiness’, ‘feeling blue’, and ‘feeling

lonely’ (for example) (Nguyen et al. 1983).

The Consumer Satisfaction Survey (CSS) is a multi-

question measure of satisfaction for services received.

Individual questions are generic in nature, such as: ‘the

location of services was convenient’ with responses on a

range from ‘strongly agree’ to ‘strongly disagree’ (Nguyen

et al. 1983).

Procedures

Following an AB (pre-test/post-test) design structure, all

participants in this study followed an identical set of pro-

cedures. Within 24 h of admission to the respite program,

the client was approached regarding the study and asked to

participate. If a client read and signed the consent form,

they immediately completed the Entrance Questionnaire.

The client then proceeded to engage in the respite program

as per the rules of the program and their admission. Seven

days following admission to the program, or within 24 h of

their discharge from the program (whichever came first)

the client was approached again and asked to complete the

Exit Questionnaire. The length of 7 days was selected

because this specific respite program’s intended stay is

between 7 and 10 days. It is therefore expected that any

improvement for a client would occur within that duration.

The entire sampling procedure, consent representation and

documentation, research methods, and data analysis were

reviewed and approved by an Institutional Review Board.

Results

One-way repeated measures Analysis of Variance

(ANOVA) were performed on all measures comparing par-

ticipant responses at entrance to exit. It was found that

symptom distress improved significantly between admission

(x = 3.25, s = 0.68) and discharge (x = 3.54, s = 0.91).

Additionally, significant improvements were found for self-

esteem (Entrance: x = 3.01, s = 0.55; Exit: x = 3.29,

s = 0.71), weak improvement for mental health confidence

(Entrance: x = 3.41, s = 0.91; Exit: x = 3.75, s = 1.02),

and no significant increase or decrease for any other measure.

Entrance and Exit scores for all 6 scales were examined

as a function of age, gender, and ethnicity for exploratory

purposes. To ease calculations, Age and Ethnicity were

recoded into binary representations (Age: B18–45, 46±;

Ethnicity: White-Caucasian/Non-White/Caucasian, Black/

Non-Black, Hispanic/Non-Hispanic, Other/Specified Eth-

nicity). Age was found to be a significant factor for the

social support at entrance (p B 0.05) with younger partic-

ipants scoring higher than older participants (B18–45:

x = 3.65, s = 0.64; 45±: x = 2.32, s = 0.89). Men scored

higher than women in mental health confidence at entrance

(male: x = 4.14, s = 0.81 vs. female: x = 3.01, s = 0.70;

p B 0.05), but less strongly at exit (male: x = 4.36,

s = 0.79 vs. female: x = 3.41, s = 1.02; p B 0.1). Men

also reported a significantly higher quality of life post-

respite (male: x = 4.60, s = 0.89 vs. female: x = 2.89,

s = 1.36, p B 0.05). White-Caucasian participants repor-

ted engaging in fewer daily activities at Entrance than Non-

White-Caucasian (White-Caucasian: x = 1.43, s = 0.13

vs. Non-White/Caucasian: x = 1.65, s = 0.25, p B 0.1).

Individuals identifying as Black reported a higher level of

daily functioning at exit (Black: x = 1.70, s = 0.23 vs.

Non-Black: x = 1.48, s = 0.15, p B 0.05), and less severe

symptom distress at entrance (Black: x = 3.72, s = 0.73

vs. Non-Black: x = 3.06, s = 0.59, p B 0.1).

Community Ment Health J (2013) 49:433–437 435

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Discussion

Consistent with the findings from the Adams and El-Mal-

lakh (2009) study, this study found a general improvement

of participants’ symptom distress upon discharge compared

to when they were admitted to the respite program. In

addition to the structural similarities discussed earlier,

these studies also share a demographically similar pre-

dominately white (Adams and El-Mallakh: 78 and 50 %)

and female (Adams and El-Mallakh: 66 and 64.3 %) pop-

ulation. The use of the Symptom Distress Scale versus the

Brief Psychiatric Review Scale still indicated a significant

improvement during the course of a respite stay.

For purposes of this study, the authors considered the

utilized scales to fall into two constructs; internal con-

structs measure aspects of the participant while external

constructs measure factors relating to the participant’s

social or functional lifestyle. In addition to symptom

severity, and with the exclusion of the Quality of Life

measure, participants’ time in Respite coincided with a

significant increase in internal constructs: mental health

confidence (MHC) and (except for participants from His-

panic origin) self-esteem (RSE). It is interesting to note

that no significant change was discovered for the pre-

dominantly external constructs of the study; specifically the

social support and daily activities. Group differences (age,

ethnicity, gender) were obtained for exploratory purposes

and, despite a small sample size, significance was found for

both gender and ethnicity as it relates to mental health

confidence and symptom severity—two measures that

showed overall improvement. Additional research that

focuses on between group differences may provide clues to

their effects on general respite effectiveness.

Considering that the active role for staff in this program is

to assess and provide for the emotional, behavioral, and

sometimes physical needs of the clients, the fact that internal

constructs improved is not surprising. Keeping in mind that

the DAF is not a standardized measure, with no improvement

in external constructs it is possible that even though clients

may engage in activities in respite, this does not appear to

translate to functions in their private lives. Further research

could look at the role these constructs play outside of treat-

ment and what changes could be made to better assist clients.

Simultaneously, an improvement in internal constructs

may indicate that a client’s physical separation from an

unhealthy environment of origin combined with the sup-

port of trained professionals will positively affect a client’s

psychological well-being. It is also possible that the staff,

by providing psychological assistance outside of therapy,

are in effect enhancing the therapeutic process in which

each client is already engaged. The validity of such an

assertion will require exploration of non-therapy-specific

intervention’s impact on identified therapeutic models.

Biases and Limitations

The principal investigator of the study is employed within

the respite program in question. To compensate, the uti-

lized instruments were intentionally selected based on their

nature to be subjective to the person completing them. In

this way the researchers are distanced from the recording

and acquisition of the data and empirical integrity is

strengthened.

One obvious limitation to this study is the small sample

size (n = 14). Indeed this was a hindrance to potentially

stronger and more representative results. However limited,

the authors hope that such a study may provide focus,

frame hypotheses, and bring greater attention to appraising

the efficacy of respite programs.

The measures in this study were selected in part due to

constraints regarding staffing, time, and training and may

not be representative of the best compliment of tools to

assess a respite program. For example: it is unlikely that

change in the QOL would represent significant meaning in

a time period measuring at most a 10 day respite stay.

However, given the lack of research and data available on

respite programs, we considered the inclusion of such

measures as warranted for exploratory purposes. Further-

more, to measure true change in any of the scales used in

this study it would be helpful to look at a client’s presen-

tation after they leave the program, and not only at the time

they are discharged. Considering that the study by Adams

and El-Mallakh (2009) used the BPRS, additional research

could identify measures that more accurately assess out-

comes in the respite-specific environment. Such an

understanding will also greatly strengthen such programs

as they could be implemented to continually evaluate

program success.

Conclusion

In conclusion, measures of symptom distress, mental health

confidence, and self-esteem all improved significantly over

time spent in the respite program. However, the immediate

impact of the respite program on external indicators of

functioning were not observed. Research on these types of

respite programs is also very limited in both quantity and

scope. Greater focus on various types of respite programs

will strengthen knowledge of the effectiveness of these

programs. Future research will also want to examine

qualities of the programs themselves—such as program

policy, professional employment, and admitting criteria. A

common definition for purpose and implementation of

respite is lacking, and a better understanding of these

details could improve current programs as well as define a

structure for newly created ones.

436 Community Ment Health J (2013) 49:433–437

123

Conflict of interests The primary author is a staff member of the

studied respite program. No other conflicts of interest to note for any

authors.

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