Community crisis residences capable of providing the care and structure needed to stabilize mentally ill individuals have been operating since the Middle Ages. Many in the field are familiar with the story of the patron saint of mental illness, Saint Dympna, and the foster families of Geel (24). As the story goes, around 600 CE an Irish royal princess, Dympna, fearing her father’s incestuous intentions, ran away from home. Near Zammel her father’s spies caught up to her and had her beheaded near the Saint Martin’s chapel. The area became a place of prayer for cures for insanity, and in 1349 the first stone of Saint Dympna Church was laid. The chapel soon became a center for the treatment of mental illness and was rapidly overwhelmed by the number of pilgrims seeking relief. In order to accommodate the sick, the church began placing them with local foster families in Geel. The number of foster families has increased to this day in Belgium, where the tradition continues, albeit in a more formal fashion because foster families now receive training and financial compensation for services.

In the United States, many innovations to this ancient idea have been developed, including crisis foster homes (25). Unfortunately, it has proven very difficult to persuade people to use their homes in this fashion, and even more problematic to find psychiatrists willing to treat very sick people at home rather than in the hospitals.

With the deinstitutionalization of the mentally ill from state hospitals in the 1950s, new systems of residential community care had to be developed for previously institutionalized patients. A system of halfway houses, three-quarter-way houses, cooperative apartments, crisis lodge facilities, specialized hotels, and residential care facilities was constructed, all with the goal of aiding patients to maintain independence in the community.

The Housing Act of 1959 provided for the financing of low-income housing projects by the U.S. Department of Housing and Urban Development (HUD) yet excluded projects serving the mentally ill. Although more recent amendments to the Housing Act have removed this restriction, other regulations, such as the requirement for support services to ensure the integration of residents into the local community, hinder development of these facilities. HUD funding is not available for psychiatric care or support services. Similarly, the Community Mental Health and Retardation Act of 1963 omitted any mandate for residential facilities as a program component in community mental health centers.

Out of necessity, innovative residential programs for treating patients in acute psychiatric crisis began to arise in the 1970s (26,27,28). An early example of one such makeshift crisis residential program occurred in 1970 at Fort Logan Mental Health Center in Denver. Emergency patients who would normally have been admitted were instead placed in a “crisis hostel” in the community for a maximum of 7 days. The idea was not only to cut costs but also to give families caring for these patients a respite, as well as to maintain the continuity of the patient’s life by placing him or her in a more normal living situation. The crisis hostel was owned by a registered nurse who agreed to supervise the patients and help with medications. Several neighbors agreed to fix meals when the nurse was away. Neither the nurse nor her neighbors accepted payment for services. When compared with a control group, hostel patients had much lower inpatient readmission rates and equal ratings of treatment success (29).

Also in the 1970s, Canada experimented with another version of the Geel foster home model in which patients were placed long term in homes (30). During the 18-month period of the study, patients exhibited substantial decline in symptomatology, but no improvement in social functioning. The conclusion was that isolating patients in understaffed foster home environments was inadequate for long-term rehabilitation, but provided a low-stress place where symptoms did diminish. This illustrates that CRFs must provide case management, socialization, recreation, and vocational activities if such programs are to be effective for the mentally ill.

In the United States in the 1970s and 1980s, despite well-constructed studies comparing hospital-based treatment with alternative models (including one in which the entire state of Hawaii’s mentally ill population was assessed for placement into community-based residential facilities), it was apparent that these alternatives were not being widely adopted (31,32,33). Kiesler (10) reviewed ten such rigorous studies and concluded that even though crisis residential facilities were equal to or more effective than inpatient treatments, these results were largely ignored. Since that time others have reported similar findings that CRFs cost significantly less while being equally effective as inpatient hospitalization on measures of symptom treatment, functioning, quality of life, and patient satisfaction (30,34,35,36).

From 1992 to 2001 there were 53 million mental health visits to emergency rooms, representing a 4.9% to 6.3% increase over the prior decade (37). Health agencies have been unable to keep up with demand for sufficient residential treatment programs. In some cases, corporations and nonprofit and private foundations, such as the Robert Wood Johnson Foundation Program on Chronic Mental Illness, have aided by expanding crisis housing options for people with mental illness (38). Because about 30% of the 3,500,000 homeless individuals in the United States have mental health issues, it is likely that the number of individuals needing crisis residential housing is much greater than those already in treatment facilities.

Typically, a minimum medical workup prior to admission to a CRF is required, including a medical screening exam, vital signs, history of presenting condition, review of systems, and focused physical exam. Medications should be ordered, laboratory and radiology studies completed, and follow-up care arranged before transfer to a CRF because these community facilities have less access to services than emergency or inpatient units. All documentation should meet standards of care, be in conjunction with local licensure and accreditation requirements, and be kept in the medical records of both the origin and destination facilities. Patients need to be informed of the process, with the crisis facility of origin working to facilitate the written consent process.

Advocacy is one of the greatest tools consistently correlated with success. Completing the process of admission may be time-consuming, complex, and at times frustrating for those less tolerant and overwhelmed by their illness. Yet, with emergency room environments at high volume, discharge to a CRF, where the environment is more conducive to stabilization, is clinically worth the extra time and effort.

Individuals admitted to CRFs from emergency services are of three main groups: (a) persons with chronic mental illnesses experiencing episodic recurrence and requiring periodic restabilization; (b) persons, often youth, experiencing acute crises without extensive histories of hospitalization; and (c) persons who are decompensating secondary to their environment (11). A fourth group might include clients admitted to a CRF as a “preventive intervention” specifically when further decompensation will likely lead to hospitalization in the near future, or when family or caregiver respite is required. Appleby and Desai (26) found that chronically mentally ill patients with three or more hospitalizations a year were the most likely to have residential instability and require a CRF. Age, diagnosis, race, special population status, veteran status, and the presence of comorbid substance abuse are frequent characteristics determining admission to CRFs.

Referrals come from single or multiple sources, such as community hospitals, emergency rooms, shelters, urgent care facilities, and forensic agencies, as well as from the public at large. At the PES of San Francisco General Hospital (SFGH), approximately 700 patients are fully evaluated per month. Over the last 20 years, 10% to 20% of patients evaluated at SFGH’s PES were diverted from inpatient hospitalization to a variety of CRFs run by the Progress Foundation. These CRF programs differentiate themselves regarding their ability to accept patients at various levels of physical and psychological functioning, insight into their illness, willingness to participate, and their cultural and multilingual capability, as well as degree of substance abuse problems.

Another example facility, the Oasis House in Boston, Massachusetts, has an average length of stay of 4 to 6 months and receives referrals from a variety of sources, although entry is through a single agency serving the homeless. Priority is given to those patients not engaged in treatment, in denial of their psychiatric illness, and displaying suspicious, disruptive, intrusive, noncommunicative behaviors or who are malodorous (27). Expectations at Oasis House are few. As described by Reilly et al. (27), “the philosophy of the [Oasis] house is to engage the clients slowly. First encounters by psychiatrists and nurse-practitioners are often social ones—for example, sharing a cup of coffee.” Alcohol and illegal drugs are tolerated at Oasis House, practicing harm reduction. Substance abuse is not ignored, but addressed and treated whenever possible. These types of programs have since been termed wet houses, or the less tolerant moist houses. An example can be found in San Francisco’s Tenderloin slum hotels. As in many urban centers, low-rent hotels contract several floors of rooms to the city to house the mentally ill. Clients residing in these hotels receive case management, and, depending on the management of the hotel, substance abuse is more or less tolerated. Overall, despite successes of flexible CRFs, exclusionary policies persist and most only admit clean and sober individuals. Few CRFs accept clients on an involuntary basis.

Prior to CRF admission, the most frequently reported housing arrangements are independent living, with family, in a board and care or group
facility, or homeless (28,29,39,40,41). Homelessness imposes a set of special problems. The predicament gives rise to a repugnant social learning that is in direct conflict with the expectations of our genial society. Albeit functional in certain situations, these often repulsive behaviors of the homeless mentally ill promote shelterization and can create barriers to health care, housing, and financial benefits, and prevent the accomplishment of even common tasks such as getting service in a grocery store. Improving self-esteem plays a central role in emotional life (31). CRFs provide this through a tolerant environment before patients move on to longer-term housing.

Many CRFs accept difficult patients. Patients referred have multiple recent emergency room or hospital admissions, and a growing number have forensic psychiatric histories. Exclusions to some CRF admissions are acute suicidal or homicidal ideation with intent or plan, dementia, severe developmental delays, neurodegenerative conditions, and flagrant psychosis causing disruptive or dangerous behaviors that require seclusion, restraint, or other supportive maintenance and structured milieu. Also excluded from CRFs are patients who have exhibited extremely poor outcome after prior CRF admission or who have harmed staff or other patients when previously admitted. Suicidal or homicidal ideations can be acceptable in more structured and adequately staffed CRFs. Patients with dementias, however, as well as disorders associated with poor impulse control, are largely unsuited for crisis residential treatment programs. Such patients should be referred to specialized units whenever available.

The exact reduction in percentage of inpatient admissions by using CRFs is difficult to measure, largely because such facilities are in high demand and fill their beds rapidly. CRFs in urban centers cannot keep pace with the demand. Still, where CRFs are present, psychiatric emergency room staff should view every patient as a possible candidate for a CRF admission.

Fiscal and licensure dictates have not deterred CRFs from attempts at creativity and expression. Most CRF variants minimize institutional features, emphasizing what has become known as sensory-based approaches (42). Sensory-based approaches involve calming or engaging environmental stimuli, such as fish aquariums or bubble lamps (sight); music rooms or fountains (sound); cups of warm tea or lavender, vanilla, orange, or other refreshing odors (smell); availability of squeeze balls, carpets, or weighted blankets (touch); salty, sour, or sweet foods (taste); and glider rockers and heavy exercise (visceromotor). All are part of what Wilbarger coined the “sensory diet” (43), which may be designed to relax or to invigorate, promoting participation, improving quality of life and compliance, and decreasing conflicts at all levels of psychiatric care.

Beyond the observation that a normalizing, multisensory environment can soothe a client, Kresky-Wolff et al. (44) stated that a homelike environment brings out the best in patients by encouraging them to behave as responsible members of a temporary family. Functional expectations for being “house appropriate,” such as helping to cook and clean and socializing with the other members of the program, are encouraged by an environment of attractive furnishings and decorations.

Most CRFs are unlocked and under a curfew. At times patients may have an adverse reaction to overstimulation or a transferential reaction to reminders of their home of origin, inducing anxiety, increased psychosis, or aggression. CRF staff should have specific training to know how to respond to agitated patients, maintain professionalism during a crisis, and keep calm in the face of their patient’s hostility while simultaneously keeping alert to the patient’s medical state, abnormal vital signs, and other signs of deterioration or delirium.

CRF staffing patterns vary widely. Flexibility among individual staff is crucial. Patients never present the same way twice, and often find themselves breaking rules and testing boundaries in endlessly unpredictable ways. Thus, CRF staff need to be flexible, creative, and actively educated. Staff should frequently attend meetings with individual client case workers to
discuss therapeutic techniques and patient management. Quandaries, as they arise, should be addressed, and harm reduction or treatment plans altered.

What patients request most of staff is round-the-clock access for help with emotional problems (45). Engagement with the client should use a carrot rather than a stick whenever possible. Initially, “engagement” should not be mistaken as a two-way street. At first, clients may seem rejecting of care. Even when patients are truly disinterested in caregivers—detached, spiteful, or rejecting—the caregiver needs to remain engaged with the patient. Professionalism such as this promotes compassion, improves the efficacy of treatments, and improves job satisfaction and staff retention. CRFs frequently utilize paraprofessionals, individuals who have received only minimal mental health training (46). New CRF personnel should be selected partially on the basis of interest and enthusiasm for working with a very disadvantaged client group, qualities often more important than professional credentials.

That CRFs are cost effective has been assumed more often than formally measured. One argument against CRFs being cost effective is that stays in CRFs are often longer than hospitalization. Also, the use of inexperienced paraprofessional CRF staff, combined with less frequent physician and medical staff supervision of patients, may lead to more frequent decompensation and elopements, increased relapses, and longer periods of disability. Although there is little empirical supporting evidence, CRF paramedical personnel are commonly believed to provide little or no effective treatment, functioning more as building managers than mental health professionals. It is also argued that CRFs do not actually serve the most severely mentally ill and that in reality they target a less disabled population (8).

No conclusive, systematic comparison of residential programs exists. This said, almost every author reports tentative conclusions that CRFs are not more expensive than hospitals. CRFs typically cost a few hundred dollars per day versus a few thousand for hospitalization or an emergency room visit. Predicted savings of CRFs versus single-episode inpatient hospital stays range from 20% to 65% (47,48). CRFs are less expensive because direct service staff cost, capital costs (building and equipment), and operating costs are half the cost of such services in inpatient hospitals (35). How a CRF is financed is the crucial determinant of program success. Funds for CRF operation are found within currently available funding streams, such as Medicaid, Medicare, private payers, private insurance, and local and state mental health authorities.

Postdeinstitutionalization, governmental mental health agencies began placing patients into neighborhoods where they were often less than welcome. Society approves of outreach teams removing the homeless or mentally ill to crisis centers and hospitals, but there is little evidence that it heartily embraces psychiatric residences of any kind, especially in the United States. Neighbors to these facilities often harbor an “anyplace but here” attitude, believing the mentally ill change their neighborhood’s character, cause declines in property value, and raise fears of personal safety (49). Resultant community backlash—commonly referred to as NIMBY (“not in my back yard”) syndrome, is widespread even though claims of adverse effects on neighborhoods appear to be groundless (50,51,52

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