Peer-run and alternative crisis services

1. Introduction

Version followed: WHO (2021) technical package Mental health crisis services: promoting person-centred and rights-based approaches (Link House section, data to 2017–18), with each service's own published self-description; for the Western Lapland Open Dialogue crisis service, Seikkula (2021) and Valtanen (2019); for Tupu Ake, the provider's own pages (Pathways), Te Pou's 2018 workforce stocktake (Appendix D), the Mental Health and Wellbeing Commission's 2024 Acute options for mental health care insights paper (which includes a Tupu Ake case study with staff and guest accounts) and its 2025 crisis-response literature scan. The WHO package's own Open Dialogue and Tupu Ake sections are not drawn on here [uncertain]. Link House's referral route is cross-checked against a 2022 inquest notice. Open Dialogue as a therapy is covered in guide 022; this guide covers only how the crisis service is organised and used.

This entry is not a single therapy. It is a family of services: residential or home-based alternatives to psychiatric admission that respond to a mental health crisis without coercion, keep the person in or near their community, and give lived experience a central role [source: WHO-C intro; WHO feature story]. WHO's 2021 guidance presents three of them as good practice [source: WHO-G contents, sections 2.1.2–2.1.4]:

• Link House, Bristol (England): a 10-bed, women-only residential crisis house run since 2010 by the NGO Missing Link inside the NHS-funded Bristol Mental Health consortium. Non-medical, social model, stays up to four weeks [source: WHO-C §2.2]. Places are commissioned for the NHS by the local Clinical Commissioning Group, and staff are support workers rather than medical professionals [source: INQUEST 2022]. Whether Missing Link still operates it under that name today was not confirmed [uncertain].
• Tupu Ake, Papatoetoe, South Auckland (Aotearoa New Zealand): opened in 2008 by the NGO Pathways, which calls it the first peer-led acute alternative service of its kind in New Zealand [source: Pathways]. It is a ten-bed, seven-night peer-led alternative to acute admission, run as a partnership between the DHB's clinical services and the NGO, offering acute care in a homelike environment to people who would otherwise need inpatient admission; it was co-designed with guests and DHB and NGO services [source: Te Pou 2018, App. D and glossary]. Set in a 1912 villa, with a day programme for up to five [source: WHO feature story; Healthpoint].
• Open Dialogue crisis service, Western Lapland (Finland): not a separate house but the whole public psychiatric system of one catchment area (Keropudas Hospital, Tornio, and its outpatient teams), organised so that any crisis gets a home-based network meeting within 24 hours [source: Seikkula 2021; IMHCN; Valtanen 2019].

Core idea of change. A crisis is treated as a human, social event to be met early, voluntarily and in ordinary surroundings rather than as an emergency to be contained. Change is expected to come from (a) safety without force, (b) being heard and keeping control over one's own decisions, including medication, (c) relationships with peers or a stable team, and (d) staying connected to family, network and community, so the person leaves with more ability to cope and repaired relationships rather than a hospital episode [source: WHO-C §2.2; WHO feature story on the Tupu Ake evaluation; Seikkula 2021].

Your role as a psychotherapist. You will usually be the referrer, the continuing outpatient clinician, or a staff member or team member inside such a service. You do not "deliver" peer support; at Tupu Ake the peer relationship belongs to peer staff. Section 4 is therefore written as the concrete procedures each service publishes, followed by tasks for a clinician working with them [synthesis].

2. Framework

No service publishes a manualised phase model; the stages below are the course of a typical crisis contact as the sources describe it [synthesis of the cited service descriptions].

Criteria for moving between stages (as published):

• Into a crisis house (Link House): woman 18+, in crisis, needing time away from home, wants to stay, can manage own personal care. Psychosis, suicidal thoughts, a Community Treatment Order and substance use "if making good progress" are not exclusions; detained women may move in as early discharge [source: WHO-C §2.2].
• Out to NHS crisis team or inpatient care (Link House): when her state makes her or others feel unsafe; the house is "a safety net, not a crisis unit" in WHO's paraphrase [source: WHO-C §2.2]. Staff may also refer elsewhere when they cannot support her given current residents' needs [source: WHO-C].
• Hospital in Western Lapland: a short admission agreed with the network; the outpatient team stays in charge [source: Valtanen 2019]. Involuntary treatment only after a safety assessment, often done collaboratively, with the psychiatrist making the final legal decision [source: Valtanen 2019].
• Tupu Ake: the service is for people who would otherwise need an inpatient admission, and the stay is capped at seven nights [source: Te Pou 2018]. The Te Pou evaluation lists among its objectives to "safely prevent avoidable hospital admissions and avoidable compulsion" [source: Te Pou evaluation]. Formal admission, exclusion and discharge criteria are not published [uncertain]; ask the service and the referring team.

3. Guiding principles

Shared rights-based principles (WHO frames all three services around these) [source: WHO-C; WHO-G]:

• Voluntariness: stay only if she wants to. In practice, confirm consent at entry and again whenever the plan changes.
• No restrictive practices: no seclusion, restraint, locked doors or compulsory routines in the house. In practice, routines are offered, not enforced [source: WHO-C §2.2].
• Self-determination and legal capacity: the person decides about medication and plans. In practice, Link House residents keep and manage their own medication, and refusing it does not end the stay [source: WHO-C].
• Listening first: understand the person's own account before acting. In practice, staff stay with an undecided woman (if she does not object) rather than pushing a decision [source: WHO-C].
• Community inclusion: keep work, groups and relationships going during the crisis. In practice, residents are encouraged to continue their usual activities [source: WHO-C].
• Participation and co-production: people with lived experience shape the service. In practice, a past-residents' reference group meets every six weeks; at least 20% of volunteers are peers [source: WHO-C].
• Recovery orientation: strengths-based, holistic, trauma-informed social model [source: WHO-C].
• Accountability: a complaints route a third party can use on the person's behalf [source: WHO-C].

Tupu Ake peer values (Pathways' published peer values) [source: Jobspace ad; the same six headings structure the Te Pou evaluation of Tupu Ake, subtitled "Whatever it takes"]:

• Mutuality: the relationship runs both ways. Meaning: peer staff are not "above" guests.
• Experiential knowledge: lived or living experience is a skill, used intentionally. Meaning: self-disclosure is purposeful, for the guest's recovery.
• Self-determination: the guest leads.
• Participation: guests take part in decisions about their stay.
• Equity: fair access and treatment.
• Hope and wellbeing: hold the expectation of recovery (the evaluation heads this value "Recovery and hope") [source: Jobspace; Te Pou evaluation].
• "Whatever it takes" spirit (wairua): personalised, flexible support rather than fixed programmes.

Western Lapland Open Dialogue principles (seven, after Aaltonen et al. 2011, as listed by Seikkula 2021): immediate help (first meeting within 24 h); social network perspective (involve family and network from the start); flexibility and mobility (need-adapted methods); responsibility (a case-specific responsible team); psychological continuity (same team throughout, across settings); tolerance of uncertainty (avoid premature decisions and conclusions); dialogism (generate dialogue and a shared language) [source: Seikkula 2021]. Also: transparency, i.e. all discussion and treatment decisions happen openly with the person and family present [source: Seikkula 2021]; non-hierarchy, i.e. the psychiatrist's view is one voice among others [source: Valtanen 2019]; family involvement is voluntary, i.e. relatives are not invited against the person's objection, and safety or abuse concerns take priority [source: IMHCN]. Full detail: guide 022.

4. Intervention inventory

These are service procedures, not psychotherapy techniques. Items 4A–4C are what each service publishes about its own practice; 4D lists the tasks of a clinician who refers to, works alongside or works inside such a service [synthesis unless tagged]. Example language is illustrative throughout.

4A. Link House (Bristol), as described in WHO 2021

A1. Referral and suitability conversation

• Purpose / when: decide together whether a stay fits; used for every enquiry, whether self-referred or from services [source: WHO-C §2.2].
• Steps: (1) take the call from the woman herself or a referrer; (2) staff speak with her directly, not only with the referrer; (3) if needed, meet her in person; (4) check fit against current residents' needs and staffing; (5) if not now, explain why and refer onward (homeless women may be placed in other Missing Link accommodation) [source: WHO-C]. Note: one current directory lists referral via the local NHS trust only; confirm the live route before telling a client she can self-refer [source: BWV] [uncertain].
• Example language (illustrative): "Can you tell me what's been happening and what you'd want from a few weeks away from home?"
• Watch for: a referral driven by family or services when she herself is ambivalent; personal-care needs beyond what the house can meet (exclusion criterion) [source: WHO-C].

A2. Confirming a genuine wish to stay (voluntary entry)

• Purpose / when: at first assessment and arrival; makes the stay voluntary in substance, not just on paper [source: WHO-C].
• Steps: (1) ask directly whether she wants to come; (2) explain house rules (respect, safety, no smoking or alcohol, limited visiting), self-managed medication and that she can leave; (3) if unsure, stay with her without pressing, provided she does not object [source: WHO-C]; (4) record her decision in her words [synthesis].
• Example language (illustrative): "There's no pressure to decide this minute. I can sit with you while you think about it, if that's OK."
• Watch for: acquiescence ("whatever you think"); a stay used to avoid a hospital she fears without real buy-in [synthesis].

A3. Tailored goal programme with a daily one-to-one hour

• Purpose / when: from the first days; turns a crisis stay into active recovery work on something she chooses [source: WHO-C].
• Steps: (1) she names one area of life she wants to improve; (2) staff build a programme around it; (3) her own support worker gives one hour a day of one-to-one work on it; (4) areas published include self-care, money, cooking and domestic skills, time management, relationships, employment and parenting [source: WHO-C]; (5) review progress each session and adjust [synthesis].
• Example language (illustrative): "Of everything going on, which one area would make the biggest difference if it got a bit easier?"
• Watch for: goals set by staff rather than her; a goal too large for a four-week stay (narrow it) [synthesis]. Working: she arrives at the hour with her own agenda.

A4. Group recovery sessions and daily activities

• Purpose / when: two or three group recovery sessions a week plus daily activities such as holistic approaches and mindfulness [source: WHO-C].
• Steps: offer, never require; keep a visible weekly timetable; let residents shape content (they asked for more activities in the 2015–16 exit survey) [source: WHO-C; timetable is synthesis].
• Example language (illustrative): "The group this afternoon is on sleep. Come along if you'd like; it's fine to just listen."
• Watch for: residents who are too distressed for groups (offer one-to-one time instead); mindfulness exercises that increase distress in trauma survivors (offer an eyes-open, shorter option or stop) [synthesis].

A5. Wellness Recovery Action Plan (WRAP)

• Purpose / when: during the stay, to leave with her own written plan for staying well and handling future crises; current care providers are included [source: WHO-C]. 88% of residents found it helpful [source: WHO-C].
• Steps: (1) introduce WRAP as her document, not a clinical form; (2) work through it in one-to-one time; (3) with her consent, involve her current care coordinator or GP; (4) she keeps the plan and decides who gets a copy [source: WHO-C for inclusion of providers; steps 1, 2, 4 synthesis]. WRAP is a published self-management system; follow its own materials rather than improvising content [uncertain: WRAP's sections].
• Example language (illustrative): "What would people around you notice first if things were starting to slip, and what would you want them to do?"
• Watch for: a plan written by staff in clinical language; plans that never reach community teams.

A6. Recovery Starchart

• Purpose / when: a structured self-rating of progress across ten life domains, done during the stay and available for her to revisit after leaving [source: WHO-C].
• Steps: complete it collaboratively at entry and before exit; discuss differences; give her a copy [source: WHO-C for use and revisiting; timing synthesis]. Do not reproduce the tool's domains or scales; use it only as your organisation is licensed to [synthesis].
• Watch for: using the chart as an eligibility or performance test rather than a conversation.

A7. Self-managed medication

• Purpose / when: throughout; protects legal capacity and choice [source: WHO-C].
• Steps: she keeps and takes her own medication; staff neither monitor nor administer it; declining medication does not affect her stay [source: WHO-C]. If she asks for help, support her to talk with her prescriber, with an advocate if she wishes [synthesis based on WHO-C advocate provision].
• Example language (illustrative): "Your medication is yours to manage here. If you want to talk through whether it's working, I can help you prepare for the GP."
• Watch for: stockpiling or overdose risk: discuss safe storage with her as part of the safety plan, consensually [synthesis].

A8. Advance plans and advocacy

• Purpose / when: when she wants future crises handled her way, or support in medical appointments [source: WHO-C].
• Steps: encourage advance planning; arrange an advocate to attend doctor's appointments if she wants one [source: WHO-C].
• Example language (illustrative): "Would it help to write down now how you'd want to be treated if you're in crisis again?"

A9. Community linking and keeping ordinary life going

• Purpose / when: from day one through exit; prevents the stay becoming a retreat from life [source: WHO-C].
• Steps: (1) encourage her to keep regular activities, work and groups; (2) connect her, by her preference, to employment support, CV help, training and other Missing Link programmes; (3) residents cook and share the house together [source: WHO-C].
• Watch for: complete withdrawal; leaving without any continuing link (residents asked for more follow-up after leaving) [source: WHO-C].

A10. Escalation when the house is no longer safe enough

• Purpose / when: when her state makes her or others feel unsafe [source: WHO-C].
• Steps: refer to the NHS crisis team or inpatient services [source: WHO-C]. Do it transparently: tell her what you are worried about, what you will do and who you will call, and invite her view first [synthesis]. Staff training covers suicide awareness, self-harm minimisation, de-escalation, alternative coping strategies, safeguarding and mental health first aid [source: WHO-C]; specific procedures were not published [uncertain].
• Example language (illustrative): "I'm worried we can't keep you safe enough here tonight. I'd like to call the crisis team with you. What would you want them to know?"

A11. Co-production and resident voice

• Purpose / when: ongoing [source: WHO-C].
• Steps: residents agree among themselves on visiting slots and have a say in day-to-day running; a reference group of past residents meets every six weeks and is consulted on rules, policy and activities; focus groups and exit surveys shape changes; a complaints route can be used by a third party [source: WHO-C].

4B. Tupu Ake (South Auckland)

Published sources describe the service in outline; the detail below comes from the provider, Te Pou and the Mental Health and Wellbeing Commission's 2024 case study, and no published operating manual exists [uncertain]. Staffing, reconciled: the core of the service is peer workers, with clinical support available when required [source: Te Pou 2018]; the Commission describes peer support combined with on-site clinical input and lived-experience leadership [source: MHWC 2025], and its case study says clinicians work with peers and the guest to develop the plan together [source: MHWC 2024, p. 38]; a directory lists registered nurses, peer support specialists and counsellors, and the peer job advertisement describes a team of Peer Support Specialists reporting to a Team Coach [source: Healthpoint; Jobspace]. Read together: a peer-delivered service with clinical (nursing) input; whether a clinician is on site at all hours, and the current ratio, are not published [uncertain]. Compulsion: the service set a boundary against compulsory-assessment notices being served on site and then worked out with the clinical team how clinicians could be present without that [source: MHWC 2024, p. 38]; as a referrer, keep any compulsory process away from the house. Culture: sources describe a voluntary, home-like setting that supports emotional and cultural safety [source: MHWC 2025] and services delivered in partnership with guests and their whānau [source: Te Pou 2018]. No published source describes Tupu Ake as a kaupapa Māori service or describes specific Māori or Pasifika practices there, so none is described here [uncertain]. Cultural authority: within Pathways, te ao Māori leadership sits with its Te Kahui Kōkiri team, led by the Kaihautū, alongside a Māori staff wānanga [source: Pathways]; for an individual guest, cultural direction rests with the guest, their whānau and the cultural supports they choose. A non-Māori clinician's role is to refer, support and partner, not to lead cultural practice [synthesis].

B1. Referral as an alternative to hospital admission

• Purpose / when: an adult in acute distress who would otherwise be admitted [source: Te Pou; WHO feature story].
• Steps: referral comes from public clinical mental health teams (most referrals historically from DHB teams), with whom the service is run in partnership; self-referral is not listed [source: Healthpoint; Te Pou 2018]. As referrer: (1) offer it to the person as a real choice, not a placement; (2) explain it is peer-led, voluntary, short (up to seven nights) and guided by their own understanding of what they need [source for features: Te Pou 2018; MHWC 2025]; (3) hand over what the person agrees to share, and ask whether whānau should be involved; (4) agree who remains their clinical contact during and after the stay [steps 1, 3, 4 synthesis].
• Example language (illustrative): "There's a house in Papatoetoe run mostly by people who've been through crises themselves. You'd stay up to a week. Would you like to hear more?"
• Watch for: offering it only after hospital is refused; a person who expects clinical treatment there.

B2. Short-stay and day programme

• Purpose / when: short overnight stays (up to one week, up to 10 guests) or day support (up to five people) [source: WHO feature story; Te Pou; Healthpoint; MHWC 2024, p. 27].
• Steps: no daily timetable is published [uncertain]. The sources describe a calm, homelike villa and garden and day-and-night support [source: Healthpoint; Jobspace]; voluntary, non-judgemental, trauma-informed engagement [source: MHWC 2025]; support led by guests' understanding of their own needs and delivered in partnership with guests and whānau [source: Te Pou 2018]; staff work three 8-hour shifts including an awake night shift [source: Jobspace]. Because a week is short, staff describe the stay as preparation for going home rather than full recovery [source: MHWC 2024, p. 36]; see B6.

B3. Intentional peer support relationship

• Purpose / when: the core of the stay; recovery supported by people with lived experience who engage guests through that shared experience [source: Wise Group article; Jobspace; MHWC 2024, p. 27].
• Steps (as published): peer specialists draw intentionally on lived or living experience, follow peer training, competencies and the six peer values (§3), and offer personalised support; Intentional Peer Support training is a desirable qualification [source: Jobspace]. In the Commission's case study, peers share their own recovery to show that things can improve, use purposeful self-disclosure to build trust and mutual understanding, and meet guests where they are; staff describe lived experience as the asset that cannot be taught, while other skills can be [source: MHWC 2024, pp. 27, 34–35]. As a practice sequence: (1) meet the guest as a person, not a case; (2) disclose only what serves the guest's situation; (3) follow the guest's own account of what is wrong and what they need. Steps 1–3 summarise the case study and are not a published protocol; do not assume Tupu Ake uses a particular named model [uncertain].
• Example language (peer staff, illustrative): "I've had nights like this. What's it like for you right now?"
• Watch for: peer staff pulled into clinical roles (medication rounds, risk policing) that undermine mutuality [synthesis].

B4. Peer co-learning and coaching

• Purpose: keeps peer practice peer-led [source: Jobspace].
• Steps: monthly co-learning (peer supervision) and coaching; peer staff report to a Team Coach [source: Jobspace].

B5. Relationship and self-determination outcomes to build on

• Purpose: the 2017 independent evaluation (qualitative interviews) found more self-determination, better ability to cope, higher satisfaction and shorter average stays than inpatient care, and repaired relationships with family and social networks [source: WHO feature story; Te Pou].
• Clinician use [synthesis]: in follow-up, ask what helped them cope at the house and which relationships changed, and build that into the outpatient plan.

B6. Wellness plan, day-stay step-down and return home

• Purpose / when: from early in the stay, to prepare the guest to go home and pick up their community ties and shared responsibilities [source: MHWC 2024, p. 36].
• Steps: (1) the guest builds a wellness plan with peer staff, which is central to preparing for home [source: MHWC 2024, p. 36]; (2) where the plan involves clinical care, clinicians, peers and the guest develop it together [source: MHWC 2024, p. 38]; (3) after the overnight stay, day stays can give continuity and a gradual step-down, and guests describe knowing the service is there as a backstop [source: MHWC 2024, p. 37]; (4) as the outside clinician, ask for a copy with the guest's consent and book your first contact before they leave [synthesis].
• Example language (illustrative): "A week goes quickly. What would you need in place at home on day one, and who would you want to know about the plan?"
• Watch for: a plan written for the guest rather than by them; discharge into an empty diary with no day-stay or outpatient contact arranged [synthesis].

4C. Open Dialogue crisis service (Western Lapland)

The dialogical method of the meetings is described in guide 022. Below are the crisis-service procedures as Seikkula (2021), IMHCN and Valtanen (2019) describe them. Valtanen writes about the adolescent outpatient team (ages 13–23); generalising to adults is [uncertain].

C1. Low-threshold first contact

• Purpose / when: any crisis, from anyone [source: Valtanen 2019].
• Steps: no referral needed; the person or anyone in the network phones; usually a nurse on call takes the call and arranges the first treatment meeting [source: Valtanen 2019]. In Seikkula's case example a GP called the local crisis clinic and a team visited the home that afternoon [source: Seikkula 2021].
• Example language (illustrative): "We can come and meet you and whoever you'd like there, today or tomorrow. Who should be in the room?"
• Watch for: callers who are not the person in crisis: ask whether the person knows about the call and invite them [synthesis].

C2. First meeting within 24 hours, at home or a chosen place

• Purpose: meet the crisis while it is most open to change [source: Seikkula 2021; IMHCN].
• Steps: (1) meet within 24 hours; (2) at the family's chosen familiar place, home if possible; (3) with the person's consent, include the relevant network (family, school nurse, social worker) [source: Seikkula 2021; IMHCN; Valtanen 2019]; (4) do not include relatives the person objects to; safety and abuse concerns take priority [source: IMHCN]; (5) whether treatment starts is decided together in this meeting [source: Valtanen 2019].

C3. A responsible team with continuity

• Purpose: one team holds the whole episode [source: Seikkula 2021].
• Steps: form a case-specific team of 2–3 professionals from different disciplines (primary care, psychiatry, social care as relevant); it stays with the case for months or years and across hospital and outpatient settings [source: Seikkula 2021; Valtanen 2019].

C4. Daily meetings in the acute phase

• Steps: meet daily at the start if needed; at each meeting agree the time, place and participants of the next [source: Seikkula 2021; Valtanen 2019].
• Watch for: the network tiring; reduce frequency as the crisis settles, by joint decision [synthesis].

C5. Open decision-making and reflecting

• Purpose: decisions are made with the person, not about them [source: Seikkula 2021].
• Steps: discuss all options, including medication and hospital, openly in the meeting with the person and family present; team members reflect aloud with each other in front of the network, then invite the family to comment on what they heard [source: Seikkula 2021; Valtanen 2019]. Meetings serve information gathering, treatment decisions and dialogue [source: Valtanen 2019].
• Example language (illustrative): "Could my colleague and I talk for a minute about what we've heard, and then you tell us what fits and what doesn't?"

C6. Cautious, discussed medication

• Steps: in severe crises temporary medication for acute anxiety or sleep may be used, preferably a one- or two-day supply given at visits rather than a prescription; long-term medication is discussed over several meetings (benefits, side effects, personal meaning) and not started suddenly [source: Valtanen 2019]. (No dosing given here.)

C7. Short hospitalisation without handing over the case

• Steps: a short stay at the 20-bed Keropudas hospital may be agreed with the network; the outpatient team stays in charge and is joined by a hospital team [source: Valtanen 2019].

C8. Safety and involuntary-treatment assessment

• Steps: in serious crises the psychiatrist assesses safety and the need for involuntary treatment, often collaboratively, and makes the final legal decision under Finnish mental health law [source: Valtanen 2019]. The team also makes sure everyone can voice views safely in meetings, including opposing ones [source: Valtanen 2019].
• Example language (illustrative): "I'm worried about your safety, and I want to say that openly here so we can decide together what happens tonight."

C9. Team supervision and training

• Steps: weekly team meetings and team supervision; joint dialogical family-therapy training across disciplines [source: Valtanen 2019]. Original Tornio training lasted three years and qualified staff as psychotherapists; most places now use one-year training [source: Seikkula 2021].

4D. Clinician tasks when working with these services [synthesis unless tagged]

D1. Crisis-option conversation

• Purpose / when: early in treatment, before any crisis, and again when one starts.
• Steps: (1) map local alternatives (crisis house, peer respite, home treatment, open-dialogue-style teams) and their real referral routes, which can differ from published descriptions [source: BWV vs WHO-C on Link House]; (2) ask the client what helped or harmed in past crises, including hospital; (3) record their preferences in a crisis or advance plan (as Link House encourages) [source: WHO-C]; (4) share it, with consent, with the crisis team.
• Example language (illustrative): "If things got very bad again, where would you want to be, and who would you want around you?"

D2. Preparing a client for a crisis-house stay

• Steps: explain what the house is and is not (non-medical, voluntary, rules, visiting limits, own food, own medication at Link House) [source: WHO-C]; check practicalities (children, pets, work, money); agree how you will stay in touch during the stay; agree what will happen if the house cannot keep them safe (escalation route, A10).
• Watch for: clients expecting hospital-style care, or fearing that the house is a locked unit.

D3. Handover and joint working

• Steps: with consent, share the current formulation, safety plan and medication list; attend or contribute to WRAP or advance planning if invited [source: WHO-C notes current providers are included]; keep your role clear (you are not the peer worker, and in Open Dialogue you join the network meeting rather than running separate parallel decisions) [source: Valtanen 2019 on team-held decisions].

D4. Exit and follow-up

• Steps: book a contact within the first days after discharge; review their WRAP or Starchart with them; reconnect community links. Link House residents specifically asked for more follow-up after leaving [source: WHO-C].
• Watch for: the post-stay dip when support ends abruptly.

D5. Risk assessment and safety planning compatible with non-coercive care

• Steps: assess suicide and self-harm risk with standard collaborative methods; write a safety plan with the person (warning signs, coping, people, services, lethal-means counselling about safe storage or removal of means, e.g. medication held by a trusted person); state openly when you are considering escalation and why. Do not make stay conditional on medication adherence where the service does not [source: WHO-C on medication].

5. Handling problems

Tags: sourced responses carry [source]; everything else is [synthesis].

Stuck: no progress during a stay

• Link House: narrow the chosen goal to one concrete step achievable in the daily hour; revisit the Starchart together [source for tools: WHO-C; response synthesis].
• Open Dialogue: tolerate uncertainty and keep meeting rather than forcing a decision; widen the network if a key person is missing [source: Seikkula 2021 principles; application synthesis].

Ambivalence or "resistance" to the service

• Do not persuade; offer to sit with the indecision, as Link House staff do [source: WHO-C]. Name the choices honestly, including what happens if they decline. Never present a crisis house as the condition for avoiding hospital unless that is actually the local rule [synthesis].

Overwhelm or escalating risk inside the house

• Use the published escalation route: Link House refers to the NHS crisis team or inpatient services when she or others feel unsafe [source: WHO-C]. Do it with her: explain, ask her view, involve her in what is passed on. Afterwards, offer a debrief and, if she wants, a return [synthesis]. A 2022 inquest into the death of a Link House resident in October 2020, five days after an NHS-trust referral, was set to examine the reasoning behind the referral and whether the placement suited her, how risks were managed and escalated, medication support, communication with family and friends, and the emergency response [source: INQUEST 2022; its findings are not drawn on, uncertain]. As referrer, address each of these explicitly in your referral and handover: why this setting, current risk and who escalates, medication support, who the house may contact, and the emergency plan [synthesis].
• In Western Lapland, a short admission is agreed with the network and the same team continues [source: Valtanen 2019].

Medication non-adherence

• At Link House, refusing medication does not affect the stay [source: WHO-C]; at Western Lapland long-term medication is discussed over several conversations [source: Valtanen 2019]. Clinician response: explore meaning and side effects, support a conversation with the prescriber, never threaten discharge [synthesis].

House-rule conflicts (alcohol, smoking, visitors, conflict between residents)

• Rules cover respect, safety, no smoking or alcohol; visits are limited to set times and one hour and residents agree slots among themselves [source: WHO-C]. Treat breaches as a conversation about safety and the shared house, involving residents where possible [synthesis].
• Substance use: Link House accepts women with alcohol or substance problems if making good progress [source: WHO-C]; if use escalates, discuss whether a different setting fits better rather than ending the stay abruptly [synthesis].

Ruptures with staff or the service

• Use the complaints procedure (a third party can raise it) and the reference group feedback route [source: WHO-C]. In peer settings, ruptures are discussed in co-learning supervision [source: Jobspace on co-learning; application synthesis]. As the outside clinician, validate, help the person say what went wrong, and avoid siding against the service or the person [synthesis].

Family or network problems (Open Dialogue)

• Do not invite relatives the person objects to; put safety and abuse concerns first [source: IMHCN]. If a network member dominates, the team's job is to make it safe for every voice, including opposing ones [source: Valtanen 2019].

No bed, wrong fit, or not eligible

• Link House may refer elsewhere when it cannot meet her needs given current residents; homeless women may go to other Missing Link accommodation [source: WHO-C]. Women-only: refer men and non-eligible people to other options; have a second option ready before you need it [synthesis].
• Personal-care needs: Link House requires that a resident can manage her own personal care (disability suite available) [source: WHO-C].

Referral route has changed

• Published routes differ by date: WHO 2021 (data to 2017–18) describes self-referral as well as referral by services; a 2020 admission came by NHS-trust referral [source: INQUEST 2022]; a current directory lists referral via the NHS trust only [source: BWV]. No current page from the service itself was found [uncertain]. Route referrals through the local trust crisis or community team unless the service tells you otherwise, and phone the service before promising anything to a client [synthesis].

Service-level difficulties (if you help set one up)

• WHO reports for Link House: commissioners were wary of an NGO-run crisis house and it took about 18 months of advocacy with lived-experience groups and champions; there was resistance to the social model and to peer staff; a women-only design was supported by a survey of women who had used inpatient care; no new money, so funds were redirected from existing services; contracts did not keep pace with inflation; 24-hour staffing was seen as costly, and funding was supplemented by grants (the copy opened breaks off here) [source: WHO-C] [uncertain for the rest].

Cultural safety (Tupu Ake and other Indigenous or culturally grounded settings)

• No published source describes Tupu Ake's cultural practice in detail [uncertain]; the 2025 Commission scan says the setting supports emotional and cultural safety [source: MHWC 2025], and Te Pou says services are delivered in partnership with guests and whānau [source: Te Pou 2018]. Cultural authority sits with Māori: within Pathways, its Te Kahui Kōkiri team and Kaihautū [source: Pathways]; for the person, themselves, their whānau and chosen cultural supports. The Commission scan notes that outcomes improve when Indigenous peoples lead or co-govern services [source: MHWC 2025]. If the person wants a kaupapa Māori option, the Commission's 2024 paper describes such acute alternatives elsewhere in Aotearoa, open to anyone who chooses a kaupapa Māori approach [source: MHWC 2024, p. 29]. Clinician response: ask the person, and with consent the service, what cultural support they want; involve Māori or Pasifika workers and whānau as the person chooses; refer to kaupapa Māori services if they prefer; do not import or lead cultural practice yourself [synthesis].

Peer-role drift

• Peer staff being asked to police risk or medication erodes mutuality. Keep clinical and peer roles distinct and support peer supervision structures [synthesis; peer values from Jobspace].

Sources

Service and primary sources:

• [WHO-C] Mental health crisis services: promoting person-centred and rights-based approaches (WHO, 2021): contents, introduction and Link House section (pp. 16–22); also listed by PAHO.
• [WHO-G] Guidance on community mental health services: promoting person-centred and rights-based approaches (WHO, 2021), front matter and contents.
• [WHO feature story] Community-based mental health services using a rights-based approach (WHO)
• [Te Pou] Evaluation of Tupu Ake (Te Pou), summary page.
• [Wise] Leading the way in the peer-led acute alternative services (Wise Group, 2019)
• [Jobspace] Peer Support Specialist, Tupu Ake, Pathways (job advertisement)
• [Healthpoint] Pathways Health (Healthpoint directory)
• [BWV] Missing Link (Bristol Women's Voice directory)
• [Seikkula 2021] Seikkula J. Open Dialogue: a new psychotherapeutic and human rights approach to build up humanistic psychiatric services. Ricerca Psicoanalitica 2021;32(3)
• [Valtanen 2019] Valtanen K. The psychiatrist's role in implementing Open Dialogue model of care. ANZ Journal of Family Therapy 2019;40(3):319–329 (accepted manuscript)
• [IMHCN] Open Dialogue (International Mental Health Collaborating Network)

Added in verification (Oct 2026):

• [Te Pou 2018] New Zealand mental health and addiction workforce: challenges and solutions (Te Pou o te Whakaaro Nui, June 2018; workforce stocktake for the Government Inquiry), glossary and Appendix D, Tupu Ake
• [MHWC 2025] Crisis responses to mental health and/or substance use: what works? A literature scan (Synergia for Te Hiringa Mahara, August 2025)
• [Pathways] Our whakapapa (Pathways)
• [Te Pou evaluation] Evaluation of Tupu Ake: a peer-led acute alternative mental health service (Te Pou), objectives and summary charts
• [MHWC 2024] Acute options for mental health care: insights paper (Te Hiringa Mahara Mental Health and Wellbeing Commission, August 2024), Tupu Ake case study (pp. 27, 34–38) and other acute alternatives (pp. 28–33); report page
• [INQUEST 2022] Inquest opening notice concerning a 2020 death at Link House (INQUEST, 16 June 2022)

Cited as reported in the sources above: Aaltonen J, Seikkula J, Lehtinen K (2011), The Comprehensive Open-Dialogue Approach in Western Lapland I (seven principles, as listed by Seikkula 2021); Seikkula et al. (2003, 2006) Western Lapland outcome studies (as summarised by IMHCN).

Unverified or unpublished [uncertain]: the WHO package's Open Dialogue and Tupu Ake sections; Tupu Ake formal admission, exclusion and discharge criteria, daily timetable, current clinical staffing ratio and any specific cultural practice; Link House's current referral route from the service itself and current operator status; the 2022 inquest findings; WRAP and Recovery Starchart content.