Abstract
The prevalence of psychological distress and suicidality are issues of international concern. This concern includes discussion in both academic literature and the public sphere about the failure of existing services to adequately meet the needs of people experiencing acute distress and suicidal thoughts. Reflecting the medicalisation of distress and suicidality, discussion of these issues is heavily focussed on the need for an expansion and improvement of clinical services. Meanwhile, the role of non-clinical, community-based organisations in providing comprehensive support to people experiencing acute distress remains widely overlooked. Such services are scarce, and research into these services is even more so.
This thesis undertakes a realist evaluation of the Taranaki Retreat – a charitable organisation, staffed by non-clinical volunteers, which provides free respite for people who are experiencing distress and suicidal thoughts. Broadly, this thesis asks: How does respite function to support people experiencing a state of crisis? As a realist evaluation, it specifically asks: What are the key outcomes for service users of the Taranaki Retreat? What are the underlying mechanisms that generate these outcomes? And finally, What are the key contextual factors in which these mechanisms operate? By answering these research questions and developing theory at a middle-range of abstraction, this thesis aims to provide an explanation of how respite, as a non-clinical form of crisis intervention, functions to support people who are suicidal and/or acutely distressed. The purpose of developing such an explanation is to support the improvement of crisis intervention services.
Realist evaluation, which serves as the methodological framework of this thesis, is a form of theory-driven evaluation. Developing, testing, and refining a programme theory in this study involved a retroductive process over two phases of data collection and analysis. In phase one, an initial programme theory was abductively inferred following a review of related literature, interviews with the programme designers, and analysis of key policy and procedure documents. In phase two, that initial theory was deductively tested and inductively refined using data gathered from four qualitative methods: participant observation, a focus group with staff and volunteers, interviews with former guests, and a review of the case notes of those same guests. These different methods of data collection provided the diverse evidence needed for this approach and enabled triangulation of data.
The refined programme theory that emerged from the two phases of data collection and analysis identifies key outcomes of this intervention, and furthermore identifies five key mechanisms that, operating in different contexts, explain how these outcomes are generated. Three of the mechanisms relate to the fulfilment of previously unmet needs and can be collectively abstracted as ‘warmth’. The other two mechanisms relate to the removal of service users from agitating or unhelpful circumstances and can be abstracted as ‘quiet’. All five mechanisms primarily attend to secondary stressors, which are stressors arising from or exacerbated by the state of crisis itself. By removing the secondary stressors and, to a lesser extent, reducing the impact of initial stressors, these mechanisms generate five key outcomes for service users: reduced emotional distress, restored clarity of thought, reduced suicidality, restored sleep, and restored functioning. Collectively, these five outcomes constitute the resolution of a state of crisis (which can also be understood as the restoration of a state of affective and cognitive equilibrium). While the findings of this thesis indicate the ability of respite to facilitate a restored state of equilibrium, they also indicate that respite does not directly help service users develop additional coping skills or new interpretations of stressor events.
By developing a generative explanation of how respite functions to support people experiencing a state of crisis, this thesis contributes to the crisis intervention literature and also carries practical implications. First, the theory developed in this thesis demonstrates a ‘non-interventionist’ approach to crisis resolution, thereby challenging an implicit assumption in the literature that crisis resolution must be facilitated by an active interventionist (typically a health professional). Second, the prominence of the theme ‘genuine care’ within the refined theory highlights the importance of considering how people in crisis interpret the motivations of those around them. Third, this thesis illustrates that the ‘warmth’ mechanisms are enhanced by both the structure of charitable organisations as well as the use of non-professional volunteers. This serves as an argument against a trend in the literature towards promoting the formalisation of crisis resolution services along with the professionalisation of staff. Charitable organisations and non-professional volunteers should be viewed as not merely useful additions, but as bringing unique advantages that distinctly contribute to positive outcomes. Finally, the findings of this thesis suggest that the potential of respite to strengthen the spectrum of crisis responses should receive greater attention from policymakers. These findings furthermore point to the advantages of establishing crisis resolution services independently of mental health services.