Atlas›Domain V · Systemic, relational, group & community›Guide 133
Guide V-133

Peer respite houses

2012Northampton, Massachusetts
A 48 · L 40 · M 1220 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Afiya Peer Respite (Northampton, Massachusetts; opened 4 August 2012; run by the Western Mass Recovery Learning Community, now the Wildflower Alliance) as described in its FY15 annual report, staff writing and Wildflower testimony, set against the consensus minimum criteria of the 2016 Peer Respite Essential Features (PREF) survey (Ostrow and Croft). Staff practice draws on Intentional Peer Support (IPS) and the Alternatives to Suicide approach. Other respites (Wisconsin's state network; Termonn, Spokane; the NYC crisis respite centres; 2nd Story, Santa Cruz) are named as variants where their rules differ. [source: Afiya FY15 report; Davidow 2022 slides; PREF 2016]

What it is. A peer respite is not a therapy and not something a psychotherapist runs. It is a service: a voluntary, short-term, overnight stay in an ordinary house, staffed and run entirely by people with lived experience of psychiatric diagnosis, trauma, hospitalisation, homelessness, substance use or similar. It is an alternative to emergency departments and locked inpatient units. PREF defines it as voluntary, short-term and overnight, in a homelike setting, offering trauma-informed crisis support and prevention. [source: PREF 2016; Ostrow NRI slides] Afiya offers a private, lockable bedroom, stays of 1 to 7 nights for up to three guests, peer staff on site 24 hours a day, and no clinical staff or services on site. Guests do not need to be in crisis to stay. [source: Davidow 2022 slides; Stimpunks summary; Afiya FY15 report]

How change is thought to happen. Change comes from relationship rather than treatment. A distressing period is treated as a chance to learn and grow, not a risk to be stabilised. Mutual, non-coercive relationships with people who have "been there" let the guest speak openly, including about suicidal thoughts or voices, without fear of forced intervention. The guest decides what the stay is for. Being connected to a wider peer community afterwards keeps the respite a "bridge to a full life" rather than a life raft. [source: Davidow 2022 slides; Dani 2015, Mad in America; D'Isselt 2013; Alternatives to Suicide 2022]

Role of this guide. Following the Domain V rule for peer-run services, sections 2 to 4 describe what the respite itself does, as its operators publish it, so you can refer accurately and work alongside it. The clinician procedures (assessing fit, preparing a self-referral, coordinating, debriefing) are mostly my own [synthesis] and are labelled as such. The Afiya page on the Wildflower Alliance site is not drawn on here, so current Afiya rules may differ from the 2015 to 2022 sources used here. [uncertain]

2. Framework

Format. Residential, house-based, short stays. Afiya: 1 to 7 nights by design; extensions possible, usually 1 to 3 extra days; in FY15, 93% of stays were 7 days or less. [source: Afiya FY15 report] Across the 2016 PREF sample, the average stay was 5.5 days and the average maximum allowed was 8.4 days. [source: PREF 2016] Variants: 2nd Story averaged 10 days (range 1 to 52) [source: Ostrow NRI slides]; Termonn allows up to 7 nights in any 30-day period [source: Termonn guest agreement]. Staffing: Afiya had a director, a house coordinator, a team coordinator and six advocates, usually two on site in the afternoon and evening [source: Afiya FY15 report]. Across PREF programmes, about 2.7 staff per weekday shift and 1.5 overnight [source: PREF 2016]. Cost to the guest: free [source: disabilityinfo listing; Wisconsin DHS].

Phases of a stay (the order follows the Afiya sources; the phase labels are mine [synthesis]):

  1. Contact and mutual-fit conversation. Goal: both the person and the staff decide whether the house fits what the person needs now. Afiya holds this conversation in person or by phone. It starts with what is happening and how the person thinks Afiya might help. Both sides must agree before a stay is offered. [source: Dani 2015] Afiya does not ask about diagnosis, psychiatric history or medication. [source: Afiya FY15 report] Since COVID, the conversation has been by phone and includes health questions. [source: Mad in America 2020] Wisconsin respites take no drop-ins: the person must self-refer by phone before the stay. [source: Wisconsin DHS] Move on when: both parties agree the house fits and a room is free.
  2. Waitlist or offer. Not having a room was the most common reason contacts did not lead to a stay: 72% of non-admitted contacts in FY15, and 724 in 2015 and 899 in 2016. Waits can be up to a week. In FY15, 64% of good-fit guests arrived within 12 hours of an offer. [source: Afiya FY15 report; Davidow 2022 slides] Move on when: the guest arrives. Transport is usually the guest's responsibility. [source: Wisconsin DHS; Termonn guest agreement]
  3. Arrival. The guest is offered a drink or food, shown around the house and given a private room. Within a few hours they fill in a few short forms, including a "Hopes for Stay" form about what would help. [source: Dani 2015; Afiya FY15 report]
  4. The stay. The guest sets their own schedule. There are no treatment plans, required goals, groups, meetings, bedtimes or curfews. They can talk with staff and other guests, rest, keep going to work or school, and see friends. [source: Afiya FY15 report] A plan for leaving is expected from the start: guests are asked to shape the stay so they are ready to go when it ends. [source: Afiya FY15 report]
  5. Leaving, or extension. Leaving is the default at the end of the agreed stay. Extensions are possible. Staff may ask a guest to leave early if the house is not a good match. [source: Afiya FY15 report]
  6. After the stay. The guest can use Wildflower's resource centres, groups and phone line as much or as little as they like. An end-of-stay survey asks about the stay, and a later survey asks about longer-term impact. The RLC's bridging team supports people who are hospitalised. [source: Davidow 2022 slides; Afiya FY15 report]

Session count. There are no sessions. Contact is continuous over a 1 to 7 day stay. Repeat stays happen: at 2nd Story, guests stayed an average of 3 times and 41% stayed only once. [source: Ostrow NRI slides]

Clinician's parallel framework [synthesis]: (a) identify a client for whom a respite stay could prevent or follow an escalation; (b) check fit and prepare the client to make the call themselves; (c) during the stay, keep your usual appointments if the client wants that, without expecting reports from the house; (d) afterwards, debrief and build community supports so the respite does not become the client's only crisis option.

3. Guiding principles

[source for this section: Afiya FY15 report; Dani 2015; Davidow 2022 slides; PREF 2016; IPS presentation (Copeland Center); D'Isselt 2013; Alternatives to Suicide 2022; Wisconsin DHS. Practical meanings are my wording.]

  • Voluntary, self-chosen. The person refers themselves and can leave at any time. In practice: you can suggest a respite but not send someone there. A person who needs someone else to refer them may need more help than a respite can give. [source: Wisconsin DHS]
  • Peer-run with lived experience throughout. PREF minimum criteria: 100% of staff and all leaders have lived experience, and the respite is run by a peer-run organisation or has a peer-majority (51% or more) advisory group. In practice: staff relate as equals and may share their own history. They do not act as clinicians.
  • Self-determination over diagnosis. Afiya does not ask about diagnosis, history or medication, and centres people's experiences and adaptations rather than symptoms. In practice: do not send diagnostic summaries unless the client asks you to, and do not expect the house to want them.
  • No crisis needed. Afiya accepts people who are not in crisis. In practice: a respite stay can be used for prevention, not only as a last resort.
  • Guest defines the purpose. The Hopes for Stay form is explicitly not a goals sheet, and treatment plans are not required. In practice: help the client name what they want from the stay (sleep, quiet, space to explore voices, practical tasks), not what you want them to achieve.
  • Learning, not helping (IPS). The relationship moves from "me helping you" to "us learning together". In practice: staff ask and explore rather than advise.
  • Relationship, not the individual (IPS). Attention goes to what happens between people. In practice: difficulties are worked through in the relationship, not managed as symptoms.
  • Hope and possibility, not fear (IPS). In practice: the focus is where the person is going, not on predicted risk.
  • Mutuality and shared responsibility. It must work for both people, and staff raise their own discomfort openly. In practice: the guest also hears staff's limits and feelings.
  • Authentic self-disclosure. Staff share parts of their own stories where relevant, and guests can give staff honest feedback. Over-sharing is acknowledged as a risk, but blanket limits are rejected. [source: Dani 2015]
  • Tolerating uncertainty and sharing power. Staff aim not to direct people, and to respect coping that works for the person even if it is unconventional. [source: Dani 2015]
  • Flexible guidelines, not rigid rules. Afiya's guidelines are living documents; "rigid rules stem more from fear than anything" [source: Dani 2015]. In practice: expect conversations rather than rule-based discharge. Other respites have explicit written agreements; see section 4.
  • Non-coercion around suicide. No routine risk checklists; validation, curiosity and staying with the person instead of forced intervention (Alternatives to Suicide). In 2016, 16 PREF programmes did not restrict guests who expressed suicidal thoughts. [source: Alternatives to Suicide 2022; PREF 2016] In practice: your duties as a clinician do not change, but the house will not do risk assessment for you.
  • Crisis as opportunity. Staff do not aim to "stabilise" the guest. [source: D'Isselt 2013]
  • Homelike hospitality. An ordinary house, residential furniture, no reception desk, shared cooking. [source: D'Isselt 2013; PREF 2016]
  • Keep ordinary life going. Guests keep work, school and friends, and come and go. [source: Afiya FY15 report; Wisconsin DHS]
  • Bridge, not life raft. A respite cut off from a wider peer community risks repeated stays and teaches people that they must be in crisis to get support. [source: Davidow 2022 slides] In practice: plan what supports come after the stay.
  • Protecting peer integrity. Staff will not speak for guests, even when providers call. The model's authors warn that clinical or reimbursement requirements can co-opt it. [source: Afiya FY15 report; Ostrow NRI slides; Dani 2015]

4. Intervention inventory

The inventory has two parts. Part A describes practices the respite and its peer staff carry out, as the operators publish them. You do not run these. You need to know them so you can describe the stay honestly to clients and avoid working against it. Part B gives the clinician's own procedures for referring to and working alongside a respite. These are mostly [synthesis]. All example language is my illustrative wording unless it is quoted and cited.

Part A: What the respite does

A1. Mutual-fit (pre-stay) conversation

  • Purpose: to decide together whether a stay fits what the person needs now. It is not a clinical triage. [source: Dani 2015; Afiya FY15 report]
  • Steps (as published): (1) The person contacts the house. At Afiya this was in person, and has been by phone since 2020. In Wisconsin the person must phone ahead and there are no drop-ins. (2) Staff ask what is going on and how the person thinks the house could help. (3) Afiya does not ask about diagnosis, psychiatric history or medication. Since COVID it does ask health questions. (4) Both sides decide whether it fits. If it does not, staff suggest other community resources; in an emergency they point to the county crisis line or 988. (5) If it fits and a room is free, a stay is offered. Otherwise the person goes on a waitlist. [source: Afiya FY15 report; Mad in America 2020; Wisconsin DHS]
  • Example language (illustrative, staff): "Tell me a bit about what's going on, and what you're hoping a few days here might give you."
  • Watch for: exclusions that respites publish. Wisconsin: people who are intoxicated, disrespectful or verbally abusive, or who need medical care or treatment. Termonn: people who cannot manage their own medical needs. [source: Wisconsin DHS; Termonn guest agreement] Afiya does not publish formal eligibility criteria beyond fit and space. Its priority goes to Western (and, in FY15, Central) Massachusetts residents. In the FY15 report guests were adults; one listing gives age bands from 19 upwards. [source: Afiya FY15 report; disabilityinfo listing; Mad in America 2020] Minimum age 18 is stated for Afiya by Mad in America 2020. [uncertain: the exact current age rule is not confirmed on Afiya's own page]

A2. Welcome and orientation

  • Purpose: to make the house feel like a home rather than an institution, and to give the guest privacy and control from the start.
  • Steps (as published): offer a drink or food; give a tour; show the guest their private room, which at Afiya has a lock. NYC's respite has no reception desk: a peer greets people at the door, and the furniture is residential. Wisconsin respites provide a lock box for medication and valuables. [source: Dani 2015; Davidow 2022 slides; D'Isselt 2013; Wisconsin DHS]
  • Example language (illustrative): "Here's your room. It locks from the inside. Kitchen's open, so help yourself whenever you like."
  • Watch for: the guest's level of energy. Some want to talk straight away; some want to sleep. Let the guest lead.

A3. "Hopes for Stay" form

  • Purpose: to record what the guest believes will help during the stay. Afiya's staff describe it explicitly as not a goals sheet. [source: Dani 2015; Afiya FY15 report]
  • Steps: the guest fills in a few short forms within a few hours of arriving, one of which asks what would help. Examples given: quiet and sleep; a safe space to explore frightening voices or visions; practical tasks such as appointments or housing. The hopes are returned to at the end of the stay; in FY15, 86% of guests met at least one. [source: Dani 2015; Afiya FY15 report]
  • Example language (illustrative): "There are no right answers here. What would make these few days worth it for you?"
  • Watch for: hopes that are really someone else's (a family member's or a clinician's). Gently ask whose hope it is. [synthesis]

A4. One-to-one peer support using the IPS tasks

Afiya staff all completed the 5-day IPS core training, and the team coordinator is an IPS trainer. Afiya says it has no set model and keeps conversations "as organic as possible". Read the tasks below as orientation, not a script. [source: Afiya FY15 report; Dani 2015] The IPS task descriptions come from the IPS overview presentation (©2014 intentionalpeersupport.org) and a NYC respite practitioner. The full IPS curriculum (Mead's training manual) is not drawn on here. [uncertain]

  • Connection. Purpose: build a sense of belonging and trust in which both people can learn. Steps: be present and interested; notice when connection drops (IPS describes a cycle of connection, disconnection and reconnection); name it and come back to it. Example (illustrative): "I feel like I lost you a moment ago. Did I say something that didn't sit right?" Watch for: the guest acting as if they have to please staff. IPS calls mimicking the other person to please them "making noise" rather than making music.
  • Worldview. Purpose: understand how the person came to see things the way they do. Steps: ask "What happened?" rather than "What's wrong?"; explore assumptions, for example by asking what someone might say or do if that assumption were true. Example (illustrative): "How did you come to see it that way? What's happened that makes that make sense?" Watch for: staff slipping into reframing or correcting. The aim is understanding, not fixing.
  • Mutuality. Purpose: redefine help as learning and growing together, with shared responsibility. Steps: it often happens in small moments; staff share their own reactions, stories and discomfort where relevant; conversations about the guest include the guest. Example (illustrative): "I'm noticing I'm getting anxious and want to fix this for you. Can we slow down together?" Watch for: the relationship only working for one side.
  • Moving towards. Purpose: move together towards what the person wants, rather than away from what they fear. Steps: listen rather than problem-solve; make meaning together; negotiate power openly. Example (illustrative): "If this week went the way you'd want, what would be different when you leave?" Watch for: staff deciding the direction. [source: IPS presentation (Copeland Center); D'Isselt 2013]

A5. Self-disclosure and honest feedback

  • Purpose: authenticity, which Afiya staff see as necessary for meaningful peer support. [source: Dani 2015]
  • Steps (as published): staff share parts of their own story when it is relevant; guests are invited to give staff honest feedback; staff raise concerns about their own comfort or safety openly. [source: Dani 2015; D'Isselt 2013]
  • Example language (illustrative, staff): "I've spent nights like that too. What helped me won't necessarily help you, but I'm glad to tell you about it if it's useful."
  • Watch for: over-sharing, which Afiya names as a risk; disclosure that pulls the focus away from the guest.

A6. Responding to suicidal thoughts (Alternatives to Suicide approach)

The Alternatives to Suicide approach comes from the same organisation, and six Afiya team members held its 3-day training in FY15. [source: Afiya FY15 report] The approach is published for peer groups. How it is applied inside the house is not described. [uncertain]

  • Purpose: to let people talk openly about suicidal thoughts without fear of forced hospitalisation, treating suicide as an attempted solution to unbearable problems. [source: Alternatives to Suicide 2022]
  • Steps (as published for supporters): validate feelings; stay curious about what is making life hard; sit with the person, in silence if needed; ask what would make life more livable and what they need to get through now; explore whether there is someone supportive to contact together. Avoid risk checklists about plan, means and lethality; framing distress as medical or chemical; medication questions; taking over; coercion. [source: Alternatives to Suicide 2022]
  • Example language: "What do you need to get through this?" [quoted, Alternatives to Suicide 2022] Phrases to avoid include announcing that you will call crisis services, or saying "I am going to take over now". [source: Alternatives to Suicide 2022]
  • Watch for: policies vary. Most PREF programmes in 2014 and 2016 did not restrict guests who had a suicide plan, but some did. Ask each respite what it does. [source: Ostrow NRI slides; PREF 2016] Clinician duties: see B4.

A7. Space to explore voices and visions

  • Purpose: a non-pathologising place to explore frightening voices or visions. [source: Dani 2015]
  • Steps: seven permanent Afiya staff held the 4-day Hearing Voices facilitator training in FY15, and Wildflower runs Hearing Voices groups. [source: Afiya FY15 report; Mad in America 2020] How this is done one to one in the house is not described. [uncertain]
  • Example language (illustrative): "What are the voices saying today? Is there anything about them you'd like to understand better?"
  • Watch for: clients who expect the house to manage medication or symptoms. It will not. See A10.

A8. Shared daily living and meaningful roles

  • Purpose: connection through ordinary activity, and restoring a sense of being useful.
  • Steps (as published): guests help with meals; nearly all PREF programmes involve guests in cooking and provide food if guests cannot bring their own. In NYC, a guest who enjoyed feeding others became more engaged through kitchen work. Groups and activities are offered but not required: only one PREF programme required participation. [source: PREF 2016; D'Isselt 2013]
  • Example language (illustrative): "I'm making soup. Want to chop or just keep me company?"
  • Watch for: activities becoming obligations.

A9. Rest, solitude and self-care

  • Purpose: many guests mainly need quiet, sleep and safety.
  • Steps (as published): private room; no bedtimes or curfews at Afiya; shared spaces (living room, basement, meeting room, kitchen, sitting room); yoga materials, art supplies, weighted blankets and a library. [source: Afiya FY15 report; Stimpunks summary]
  • Watch for: variants with curfews. Termonn guests who leave after 10 pm cannot come back until 8 am. [source: Termonn guest agreement]

A10. Keeping ordinary life and clinical care going

  • Purpose: the stay supports the guest's life rather than replacing it.
  • Steps (as published): guests come and go for work, school, appointments and friends; Wisconsin allows visitors and asks guests planning to be away 24 hours or more to talk to staff first. There are no clinical services on site, no doctors or nurses, and no medication management. Staff help guests find clinical support in the community if they want it. At Termonn, guests manage their own medication and staff do not count, give or handle it. [source: Wisconsin DHS; Stimpunks summary; Termonn guest agreement]
  • Watch for: clients who need medication supervision or medical care during the stay. That is not a fit.

A11. Linking to community resources and the wider peer community

  • Purpose: to make the respite a bridge rather than a life raft. [source: Davidow 2022 slides]
  • Steps (as published): connect guests with community resources. Wildflower offers resource centres (Holyoke, Pittsfield, Greenfield, Springfield), peer groups (Hearing Voices, Alternatives to Suicide, LGBTQIA+, substance-related, some in Spanish), a peer support line, and a bridging team for people in hospital. Wisconsin encourages guests to complete a wellness plan, and Wellness Recovery Action Planning is a common staff training. [source: Davidow 2022 slides; Mad in America 2020; Afiya FY15 report; Wisconsin DHS; PREF 2016]
  • Example language (illustrative): "There's a group on Thursdays at the centre. Want me to tell you what it's like?"
  • Watch for: a guest with no post-stay connections at all.

A12. Ending, extending or ending early

  • Purpose: keep stays short and planned, and protect the house for everyone.
  • Steps (as published): the guest plans the stay from the start so they are ready when it ends. Extensions are possible, usually 1 to 3 days. Staff may ask a guest to leave early if the house is not a good match. Afiya uses flexible, values-based expectations. Other houses have written agreements: Termonn names bringing drugs, alcohol or weapons, threats, yelling, soliciting, and returning intoxicated in a way that affects others as grounds to be asked to leave. It also asks guests to keep other guests' stories confidential, and helps arrange a higher level of care if one is needed. [source: Afiya FY15 report; Dani 2015; Termonn guest agreement]
  • Watch for: an early ending that the guest experiences as rejection. See section 5.

A13. Follow-up surveys and phone support

  • Purpose: evaluation, and staying in contact after the stay.
  • Steps (as published): an end-of-stay survey, then a later survey by mail, email, newsletter or Facebook. Response rates in FY15 were about 30%. Wisconsin respites also offer peer support by phone; NYC runs a companion peer support line. [source: Afiya FY15 report; Wisconsin DHS; D'Isselt 2013]

Part B: Clinician procedures for referring to and working alongside a respite

These are [synthesis] unless a source is given. They are built on the published access rules above.

B1. Assessing fit before suggesting a stay

  • Purpose: to suggest a respite only to clients it can actually serve, and at the point where it can help.
  • When to use: rising distress, sleeplessness, a household crisis, voices getting louder, or suicidal thoughts the client wants to talk through without being hospitalised; as a step down after hospital; or for prevention, since Afiya does not require a crisis. [source for prevention use: Davidow 2022 slides]
  • Steps: (1) Ask whether the client wants a few days away with peers. Choice is the entry criterion. (2) Check the published exclusions: is the client able to self-refer by phone, sober enough to take part, not needing medical care or supervised medication, and able to manage their own needs? [source: Wisconsin DHS; Termonn guest agreement] (3) Check practicalities: transport, work and childcare arrangements, pets (Wisconsin allows service animals). (4) Weigh your own risk formulation. If your clinical judgement is that the client needs a level of care with medical oversight, a respite is not a substitute. (5) Look up the local respite's own rules. They vary on curfews, suicide policies, maximum stay and age.
  • Example language (illustrative): "There's a house run by people who've been through hard times themselves. You'd have your own room for a few nights, no treatment, no forms about diagnosis. Would something like that appeal?"
  • Watch for: suggesting a respite mainly because no other service has room, or to reduce your own anxiety. The client must want it.

B2. Preparing the client to make the self-referral call

  • Purpose: respites take only self-referrals, and staff will always speak to the person themselves. Providers and families may phone for information but cannot book a stay. [source: Wisconsin DHS; Afiya FY15 report]
  • Steps: (1) Describe the house honestly: peer staff, no clinicians, no medication management, a short stay, a private room, optional activities, no required groups (Afiya). (2) Explain that the call is a two-way conversation about fit, and that Afiya will not ask about diagnosis or medication. (3) Help the client think about what they would say they need. This doubles as preparation for the Hopes for Stay form. (4) Warn them about waitlists: a room may not be free for up to a week. Agree a back-up plan. (5) Offer to sit with them while they call, if they want, but let them do the talking.
  • Example language (illustrative): "When they ask what's going on, you can just say it in your own words. What would you want them to know?"
  • Watch for: a client who wants you to make the call. Name the self-referral rule and explore their hesitation. Needing someone else to refer you may indicate that more support is needed than a respite gives. [source: Wisconsin DHS]

B3. Coordinating with the respite while protecting the model

  • Purpose: to support the stay without turning peer staff into extensions of the clinical team.
  • Steps: (1) Expect no reports. Afiya staff do not speak for guests to other providers. [source: Afiya FY15 report] (2) Route any information through the client. Share it only with their explicit consent and at their request, and do not send diagnostic summaries by default. (3) If a client wants you involved, agree with them what they will tell the house, and when. (4) Keep your appointments if the client wants that; guests can come and go for appointments. [source: Wisconsin DHS] (5) Avoid asking the house to monitor, check medication or report risk. These conflict with its stated values and its scope. [source: Afiya FY15 report; Alternatives to Suicide 2022]
  • Example language (illustrative, to staff): "I'm [client]'s therapist. I'm not asking for any information. I just wanted you to know they've chosen to contact you, and they may want to bring me into a conversation."
  • Watch for: language in emails or calls that is coercive, diagnostic or risk-focused. It can damage the client's standing in the house.

B4. Your safety and risk duties around a stay

  • Purpose: your own professional duties continue; the respite does not take them on.
  • Steps: (1) Do your usual suicide risk formulation before suggesting a stay, and document why a voluntary peer setting is appropriate. (2) Make a collaborative safety plan with the client in the usual way, including people they can contact, and the crisis line or 988. (3) Lethal-means counselling: agree secure storage or removal of means at home before and after the stay. Respite guest agreements typically forbid weapons and provide lock boxes for medication. [source for house rules: Termonn guest agreement; Wisconsin DHS] (4) Tell the client honestly that you, unlike the house, may have to act if you believe their life is in immediate danger, and what that would look like. (5) Do not ask house staff to carry out risk checks for you.
  • Example language (illustrative): "The house won't do risk checks, and that's part of why it can help. I'm still your therapist, though, so let's agree what you'd do, and what I'd do, if things got much worse."
  • Watch for: the tension between the house's non-coercive stance and your duty of care. Be open about it with the client rather than hiding it.

B5. Integrating the stay into therapy

  • Purpose: to use what the client learned during the stay.
  • Steps: (1) Before the stay, ask the client what they hope for. (2) Afterwards, review those hopes, what helped, what did not, and what relationships or groups they want to keep. (3) Bring material from the stay into therapy, such as new ways of understanding voices, or experiences of mutuality. (4) Put the respite in the client's relapse-prevention or crisis plan as a self-chosen option, along with its access rules (call ahead, waitlist).
  • Example language (illustrative): "What did those few days show you about what you need when things get hard?"
  • Watch for: an idealised or a denigrated account of the house. Explore both without taking sides.

B6. Building a bridge to the wider peer community

  • Purpose: to prevent the life-raft pattern of repeated stays because there is nothing else after leaving. [source: Davidow 2022 slides]
  • Steps: (1) Map the client's peer and community supports. (2) Explore the respite organisation's groups, phone lines and resource centres (for Wildflower: Hearing Voices, Alternatives to Suicide, LGBTQIA+ and other groups). (3) Encourage a first contact while the client is still in or just after the stay. (4) Review it at later sessions.
  • Example language (illustrative): "You mentioned the Thursday group. What would make it easier to go once you're home?"
  • Watch for: repeated stays with no growth in other supports.

B7. Working alongside, or partnering with, a peer respite as a service or clinician

  • Purpose: to support the model without co-opting it. [source: Ostrow NRI slides; Dani 2015]
  • Steps: (1) Learn the PREF minimum criteria: all staff and leaders have lived experience, and governance is peer-run or by a peer-majority advisory group. (2) Respect that clinical requirements, Medicaid or licensing can push a respite towards a clinical model; 2nd Story added licensed case managers when it moved to Medi-Cal funding. (3) Offer back-up that the respite asks for, such as easy referral to clinical services, rather than oversight. (4) Recognise that respites without peer governance are a different model. [source: PREF 2016; Ostrow NRI slides; Davidow 2022 slides]
  • Watch for: proposals to add clinical assessment, medication checks or involuntary pathways to a peer respite. Its own founders argue these undermine the model. [source: Dani 2015]

5. Handling problems

The sources mostly describe how the house works, not how to handle problems from a clinician's side. Responses marked [synthesis] are mine.

  • No room / waitlist. Lack of space was the most common reason contacts did not become stays (72% of non-admitted contacts at Afiya in FY15; waits of up to a week). [source: Afiya FY15 report; Davidow 2022 slides] Response [synthesis]: plan B in advance (friends, a peer support line, more frequent sessions, crisis services if needed); encourage the client to call early, before things peak; and let the client know the respite may also offer phone support while they wait (Wisconsin). [source for phone support: Wisconsin DHS]
  • Client will not or cannot make the call. Response [synthesis]: explore what makes the call hard (shame, fear of being turned away, fear of being reported); rehearse the call; sit with them while they make it. Do not call on their behalf to book a stay; respites will not accept that. [source: Wisconsin DHS] If they cannot make the call even with support, reconsider whether a respite fits right now.
  • Judged not a good fit. Response [synthesis]: treat it as information, not rejection. Ask the client what the house said and which alternatives were suggested (staff point to community resources or crisis lines). [source: Wisconsin DHS] Review intoxication, medical needs or level of distress with the client.
  • Asked to leave early. Afiya may end a stay if the house is not a good match; written agreements elsewhere list substances, weapons, threats or not managing one's own needs. [source: Afiya FY15 report; Termonn guest agreement] Response [synthesis]: offer a session soon after; explore what happened from the client's worldview; separate the event from the client's worth; plan whether and how to approach the respite again.
  • Substance use. Intoxication rules out a stay in Wisconsin, and Termonn ends stays for substances in the house or intoxication that affects others. [source: Wisconsin DHS; Termonn guest agreement] Wildflower also runs substance-related peer groups. [source: Mad in America 2020] Response [synthesis]: talk through the house's rules beforehand; consider a harm-reduction plan for the stay; know the local rules, as they vary.
  • Suicidal crisis during the stay. The house will not do risk assessments or use coercion. It will talk openly with the client. [source: Alternatives to Suicide 2022] Response [synthesis]: keep your safety plan and lethal-means agreement current (B4); if the client contacts you, respond as you normally would; involve emergency services only on your own clinical judgement of imminent danger, and, wherever you can, tell the client what you are doing and why. Tell the client in advance that this is how you work.
  • Clinician anxiety about the model. Response [synthesis]: notice the urge to ask for monitoring or reports. Remember that the stay is voluntary, that the client is an adult choosing support, and that respites were designed as alternatives to coercive services. Use supervision for your own uncertainty rather than passing it to the house.
  • Cycling in and out ("life raft"). Wildflower warns of this when respites lack a wider community. [source: Davidow 2022 slides] At 2nd Story, longer stays were linked to more psychiatric emergency service hours. [source: Ostrow NRI slides] Response [synthesis]: put community connection at the centre of after-stay planning (B6); review what each stay achieved; explore whether repeat stays reflect gaps in housing, relationships or treatment.
  • Client uncomfortable with staff self-disclosure or mutuality. Response [synthesis]: encourage the client to give honest feedback to staff, which Afiya invites [source: Dani 2015]; explore in therapy what equal relationships bring up; not every client wants peer support, and that is a legitimate choice.
  • Client expects clinical care (medication, therapy) in the house. There are no clinical services, doctors or nurses on site. [source: Wisconsin DHS; Stimpunks summary] Response [synthesis]: correct the expectation before the call; arrange medication supply and prescriber contact beforehand; keep outpatient appointments going.
  • Ruptures between client and clinician over the respite (for example, the client feels you are "getting rid of" them, or that you disapprove of the house). Response [synthesis]: name it; restate that you remain involved; let the client lead decisions about the respite; repair in the usual way.
  • Conflict with other guests. Termonn staff try to resolve conflicts before asking anyone to leave, and guests are asked to keep others' stories confidential. [source: Termonn guest agreement] Response [synthesis]: help the client think through how they want to raise problems with staff.
  • Cultural, language, age or identity fit. Wildflower runs some groups in Spanish and LGBTQIA+ peer support. [source: Mad in America 2020] Fit for other identities is not addressed in the sources. [uncertain] Response [synthesis]: ask the respite directly about language access and how it supports people like your client; take the client's concerns seriously.
  • No respite nearby. In 2016, 33 programmes responded to the PREF survey, and only 22 met the minimum criteria. [source: PREF 2016] Response [synthesis]: look for peer support lines, warmlines, peer groups and crisis services with peer staff; some respites offer support by phone [source: Wisconsin DHS]; check whether a local programme labelled as peer respite is actually peer-run (B7).
  • Different models with the same name. Some respites are clinical or partly clinical, have curfews, or require participation. [source: Davidow 2022 slides; Termonn guest agreement; PREF 2016] Response [synthesis]: before you describe a stay to a client, find out the specific programme's governance, rules and suicide policy.

Sources

Sources

Further reading (not drawn on; cited for orientation only) [uncertain]

  • Wildflower Alliance Afiya page (wildfloweralliance.org/afiya).
  • Ostrow L, Croft B (2015). Peer respites: a research and practice agenda. Psychiatric Services, 66(6).
  • Mead S. Intentional Peer Support: An Alternative Approach (IPS core training manual), various editions; the curriculum itself is not drawn on here.
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