National Alliance on Mental Illness
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President's New Freedom
Commission on Mental Health

Achieving the Promise: Transforming Mental Health Care in America

Goal 5: Excellent Mental Health Care Is Delivered and Research Is Accelerated


5.1 Accelerate research to promote recovery and resilience, and ultimately to cure and prevent mental illnesses.

5.2 Advance evidence-based practices using dissemination and demonstration projects and create a public-private partnership to guide their implementation.

5.3 Improve and expand the workforce providing evidence-based mental health services and supports.

5.4 Develop the knowledge base in four understudied areas: mental health disparities, long-term effects of medications, trauma, and acute care.

Understanding the Goal

The Delay Is Too Long Before Research Reaches Practice

Over the years, research has yielded important advances in our knowledge of the brain, behavior, and effective treatments and service delivery strategies for many mental disorders. An array of evidence-based medications and psychosocial interventions - typically used together - now allows successful treatment of most mental disorders. Despite these advances in science, many Americans are not benefiting from these investments.6; 7

Far too often, treatments and services based on rigorous clinical research languish for years rather than being used effectively at the earliest opportunity. According to the Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century,9 the lag between discovering effective forms of treatment and incorporating them into routine patient care is unnecessarily long, lasting about 15 to 20 years.164

Even when these discoveries become routinely available at the community level, too often the clinical practice is highly uneven and inconsistent with the original treatment model that was shown to be effective.165 Extended time to conduct efficacy and other value-determining tests ensures that safeguards are in place for these proven and emerging remedies. However, follow-up be allowed to research on already proven interventions should not be allowed to hinder efforts to put that knowledge, service, treatment, and supportive service into clinical practice.

Too Few Benefit from Available Treatment

Effective, state-of-the-art treatments vital for quality care and recovery are now available for most serious mental illnesses and serious emotional disorders.18 Yet these new effective practices are not being used to benefit countless people with mental illnesses. The mental health field has developed evidence-based practices (EBPs) - a range of treatments and services whose effectiveness is well documented. A partial list of EBPs includes:

  • Specific medications for specific conditions,

  • Cognitive and interpersonal therapies for depression,

  • Preventive interventions for children at risk for serious emotional disturbances,

  • Treatment foster care,

  • Multi-systemic therapy,

  • Parent-child interaction therapy,

  • Medication algorithms,

  • Family psycho-education,

  • Assertive community treatment, and

  • Collaborative treatment in primary care.

Evidence-based practice
(EBP) is defined by the Institute of Medicine as - the integration of best-researched evidence and clinical expertise with patient values.9

Emerging best practices - treatments and services that are promising but less thoroughly documented than evidence-based practices.

Along with EBPs, the mental health field has also developed promising but less thoroughly documented emerging best practices, such as:

  • Consumer operated services,

  • Jail diversion and community re-entry programs,

  • School mental health services,

  • Trauma-specific interventions,

  • Wraparound services,

  • Multi-family group therapies, and

  • Systems of care for children with serious emotional disturbances and their families.

Despite this range of effective, state-of-the-art treatments and best practices, many interventions and supports do not reach the people who need them because of:

  • Complex reimbursement policies (if payment for the treatments is even allowable),

  • The growing crisis in workforce training,

  • The shortage of qualified professionals, and

  • The need for more research on putting new and proven methods into practice more rapidly.

The Texas Medication Algorithm Project illustrates an evidence-based practice that results in better consumer outcomes, including reduced symptoms, fewer and less severe side effects, and improved functioning.166-168 (See Figure 5.1.) However, too few consumers benefit from this practice because it is not widely used.

Figure 5-1. Model Program: Quality Medications Care for Serious Mental Illnesses


Texas Medication Algorithm Project (TMAP)


To ensure quality care for people with serious mental illnesses by developing, applying, and evaluating medication algorithms. An algorithm is a step-by-step procedure in the form of a flow chart to help clinicians deliver quality care through the best choice of medications and brief assessment of their effectiveness. The target population is people with serious mental illnesses served by public programs.


Development of algorithms as well as development of consumer education materials and other tools for treating serious mental illnesses. Public sector-university collaboration with support of stakeholders, education and technical assistance, and administrative supports to serve the most medically complex patients. Early phases of the project developed the algorithms and tested the benefits of their use; the program's latest phases focus on implementing TMAP in mental health treatment settings throughout the State.


The algorithm package implemented by Texas was more effective than treatment-as-usual for depression, bipolar disorder and schizophrenia. It reduced symptoms, side effects and improved functioning.166-168 The package's benefit for reducing incarceration is being studied. In addition, medication algorithms have been developed for treating children with depression or attention deficit hyperactivity disorder (AD/HD). TMAP algorithms have also been adapted to treat adult consumers who have co-occurring mental and substance use disorders.

Biggest Challenge

To ensure that the entire algorithm package - patient education, frequent medical visits, medication availability, and consultation - is properly implemented in other States and localities.

How other organizations can adopt

Conduct an active planning process, including meetings with stakeholders, to examine what organizational changes are needed to make the algorithm work best.


Texas; Nevada; Ohio; Pennsylvania; South Carolina; New Mexico; Atlanta and Athens, GA; Louisville, Kentucky; Washington, D.C.; San Diego County, CA; and private sector in Denver, Colorado.

Reimbursement Policies Do Not Foster Converting Research to Practice

The complexities and limitations in paying for many well-established, evidence-based practices for children and adults cause the quality of mental health services to vary greatly. In particular, Medicaid, Medicare, and private payers must keep current with advances in evidence-based practices, continuously examining practice to inform reimbursement policies.

As promising new findings are conveyed from the research community into the hands of front-line providers, policies and financing criteria at the Federal, State, and local levels must provide incentives to support adopting and using these new findings. In the current system, some disincentives exist in cases where private insurance, Medicaid, or Medicare may reimburse for a particular EBP, but the complexity of the coverage rules makes implementing it difficult. Fee-for-service reimbursement systems for Medicaid, Medicare, and other payers do not allow providers to bill for essential components of many EBP programs, such as flexible case management, non-face-to-face services, or home visits.

Many private insurers do not cover these effective supports, services, treatments or practices. While it is possible for Medicaid to cover many of these practices, the only way to access reimbursement for them presently is to navigate the system expertly enough to obtain approval to provide these services under an option or a waiver.

Serious Workforce Problems Exist

The Commission heard consistent testimony from consumers, families, advocates, and public and private providers about the "workforce crisis" in mental health care. Today not only is there a shortage of providers, but those providers who are available are not trained in evidence-based and other innovative practices. This lack of education, training, or supervision leads to a workforce that is ill-equipped to use the latest breakthroughs in modern medicine.

Despite the recognized importance of culturally relevant services, training curricula generally lack an adequate focus on developing cultural competence.

Although the supply of well-trained mental health professionals is inadequate in most areas of the country, rural areas are especially hard hit.112 In addition, particular shortages exist for mental health providers who serve children, adolescents, and older Americans.105; 169; 170

Another challenge in the mental health system is the condition of some education programs. While some graduate programs have led the field in developing and disseminating evidence-based practices, many others have not kept pace with dramatic technological developments in delivering care. Continuing education programs routinely employ teaching methods that have been demonstrated, through research, to have little effect on provider behavior or impact on consumer outcomes.171 Also, substantive training in the evidence-based treatment of mental illnesses tends not to be offered to critical segments of the workforce that have an enormous role in direct care including bachelor-level staff, paraprofessionals, primary care providers, consumers, and families.171

Despite the recognized importance of culturally relevant services, training curricula generally lack an adequate focus on developing cultural competence. Racial, ethnic, and linguistic minorities remain significantly under-represented in the current workforce.1; 104; 105 (See Goal 3 for a related discussion.)

As concepts of recovery and resiliency become key principles in mental health care, education and training programs must incorporate these concepts in their curricula, training materials, and experiences.

Four Areas Have Not Been Studied Enough

The knowledge base in the mental health system is lacking sufficient information in at least four areas:

  • Minority disparities in mental health research,

  • The long-term effects of medications,

  • The impact of trauma, and

  • Acute care.

Disparities in Mental Health Research

While many types of disparities exist in mental health care, American Indians, Alaskan Natives, African Americans, Asian Americans, Pacific Islanders, and Hispanic Americans bear a disproportionately high burden of disability from mental health disorders, not because of greater prevalence or severity of illnesses in these populations, but because they receive less care and poorer quality of care.1 Similarly, these groups are significantly under-represented in mental health research and mental health service delivery.1 (See Goal 3 for a related discussion.)

Long-term Use of Medications

Breakthroughs in developing the next generation of medications provide hope for treatment and recovery from mental illnesses. The discovery of effective treatments using medications currently on the market is also encouraging. However, since these medications are treatments and not cures, some individuals with chronic illnesses, including children, are expected to use these medications over an extended period of time. Knowledge of the clinical and economic effects of these medications is limited because systematically evaluating the maintenance use of medications is not required for FDA approval. Consequently, long-term effects have not been well studied for many psychotropic medications.

Long-term effects have not been studied well enough for many psychotropic medications.

The Impact of Trauma

Stressful life events or the manifestation of mental illnesses can upset the balance most adults seek in life, resulting in distress and dysfunction. Severe or life-threatening traumatic events experienced in childhood or adulthood sometimes lead to emotional and behavioral reactions that jeopardize mental health. The likelihood of developing post-traumatic stress disorder (PTSD) is related to pre-trauma vulnerability, magnitude of the event, preparedness for the event, and the quality of care after the event.172

Urban and Native American youth are more likely to be exposed to violence,173 while women are twice as likely to develop PTSD after they are exposed to life-threatening trauma.174 The mental health field lacks sufficient information about dealing with trauma and its effects on different populations. Also, few treatments specifically for adult survivors of childhood abuse have been studied in randomized controlled trials.175

Acute Care

Shortages exist in the availability of psychiatric beds and other levels of acute care in many regions of the country.176-178 Too often the short-term psychiatric inpatient care and emergency services in hospitals are used as the first contact for uninsured and under-insured populations. Other crisis and urgent care service settings - 24-hour care in residential treatment facilities for children, mobile crisis teams, and respite hostels - are also forms of acute care facilities. This important segment of the health care delivery system lacks essential national data, shows evidence of treatment gaps in many regions, and lacks consistent clinical standards.

Achieving the Goal


5.1 Accelerate research to promote recovery and resilience, and ultimately to cure and prevent mental illnesses.

Speed Research on Treatment and Recovery

The Commission's study has taken place in a context of enormous progress and accomplishment in the scientific study of effective treatments and services in mental health care. Research is having a significant impact on the effectiveness of the mental health care delivery system and, given the significant co-occurrence of mental disorders with general medical illnesses, on the overall quality of health care available in the U.S. Progress in understanding the causes of disorders of the mind and the brain will accelerate discovering new treatments and approaches to recovery while raising the possibility that mental illnesses will ultimately be cured or prevented.

A commitment is necessary to speed the findings of research to treatment and services providers as well as to the public as a whole. An on-going dialogue among researchers, providers, consumers, and families is vital to address research priorities, study designs, interpretation of results, and the dissemination of findings. The Commission recommends making a national commitment to continue discovering and applying improved treatments and services in mental health care, as well as creating a research program with a long-term goal of developing cures for major mental illnesses.

In addition, the National Institutes of Health (NIH), and the Substance Abuse and Mental Health Services Administration (SAMHSA) should partner with the National Institute on Disability and Rehabilitation Research to promote research on factors contributing to rehabilitation and recovery from mental illnesses.


5.2 Advance evidence-based practices using dissemination and demonstration projects and create a public-private partnership to guide their implementation.

Bridge the Gap Between Science and Service

To further advance treatment and prevention in mental health care, the Nation must continue to invest in research at all levels. These research activities must include a serious "science-to-services" endeavor, resulting in delivering the very best evidence-based practices to consumers in a timely way.

The Nation must have a more effective system to identify, disseminate, and apply proven treatments or evidenced-based practices (EBPs) to mental health care. Systematic approaches to bring scientific discovery to service providers, consumers, and families must be emphasized more. Medicaid demonstration initiatives are an essential tool to inform policy makers and Federal payers about the effectiveness and fiscal impact of health care innovations. As these new practices are identified, dissemination projects evaluating best methods for widespread implementation are needed.

Technical assistance on the importance of moving evidence-based practices into the field must accompany any reforms. This support will help alleviate the lag time between discovery and delivery, thus, bringing about a healthier, more robust population.

The Commission recommends that the Department of Health and Human Services provide leadership to evaluate implementing evidence-based interventions through dissemination projects. The Federal government should initiate and sustain a public-private partnership, with involvement and support from private foundations, advocacy groups, and professional organizations. The goal of this partnership would be to:

  • Advance knowledge,

  • Disseminate findings,

  • Facilitate workforce development,

  • Recognize those treatments and services that should be considered evidence-based, and

  • Ensure they are implemented with adequate financial support.

The partnership should comprise all stakeholders including providers, consumers, and families. It should guide and oversee many activities that are currently scattered throughout the public and private sectors, thus eliminating inefficient duplication and encouraging collaboration on potentially beneficial issues. This leadership is needed to bridge the gap between science and service.

The Commission encourages continuing and expanding the collaboration between NIH and SAMHSA to conduct rigorous peer-reviewed research. They should use both quantitative and qualitative research methods to increase our knowledge about the most effective means of disseminating and promoting evidenced-based practices. These HHS agencies have already begun a formal "science to services" process to further develop and expand evidenced-based practices in the field. They have jointly funded a grant program for State mental health agencies to begin developing the infrastructure to conduct research alongside dissemination efforts. The process should be part of a comprehensive strategy moving from science to service and from the field back to science.

To promote efficient and cost-effective practices for improved consumer outcomes, the field needs more rigorous studies of EBP dissemination efforts. One such effort is ongoing. National Institute of Mental Health and SAMHSA are collaborating to support a study on implementing the Family Critical Time Intervention Model with homeless families and their children. (See Figure 5.2.)

The Commission concludes that national leadership must overcome the fragmentation and blurring of responsibility for translating the science of mental health into clinical practice.

Toward this end, mental health field must expand its efforts to develop and test new treatments and practices, to promote awareness of and improve training in evidence-based practices, and to better finance those practices.

Figure 5-2. Model Program: Critical Time Intervention with Homeless Families


Family Critical Time Intervention model (FCTI). The program is jointly funded by NIMH and the Center for Mental Health Services/Center for Substance Abuse Treatment Homeless Families Program.


To apply effective, time-limited, and intensive intervention strategies to provide mental health and substance abuse treatment, trauma recovery, housing, support, and family preservation services to homeless mothers with mental illnesses and substance use disorders who are caring for their dependent children.


The Critical Time Intervention model (CTI) was developed in New York City as a program to increase housing stability for persons with severe mental illnesses and long-term histories of homelessness. Its principle components are rapid placement in transitional housing, fidelity to a Critical Time Intervention CTI model for families (i.e., provision of an intensive, 9-month case management intervention, with mental health and substance use treatments), a focused team approach to service delivery, with the aim of reducing homelessness, and brokering and monitoring the appropriate support arrangements to ensure continuity of care.


Data indicate that mothers in this group tend to be poorly educated, have meager work histories, and face multiple medical, mental health, and substance use problems. Their children's lives have lacked stability in terms of housing, education, and periods of separation from their mothers. African-American and Latina women were over-represented in study sites in proportions greater than the national average for homeless populations. (An NIMH-funded study of this project is ongoing; additional outcomes will be available at its conclusion.)

Biggest challenge

The CTI model for families challenges the assumption that homeless mothers with children who are have mental health or substance use disorders require confinement and extended stays in congregate shelter living before they can independently manage their own households. This can be addressed by acquiring buy-in from collaborators and involved agencies, acquiring needed housing resources, evaluating the project with respect to model fidelity, and attaining ongoing involvement of practice innovators to establish thoughtful compromises within local contexts.

How other organizations can adopt

The program is transferable to any community that can align resources needed for housing and conduct relevant training for providers in a CTI model for families. (A manual to guide program replication will be available at the conclusion of the current study.)


Westchester County, NY

For additional information


Change Reimbursement Policies to More Fully Support EBPs

Successfully transforming the mental health system, hinges, in part, on better balancing fiscal resources to support using proven, evidence-based practices. The Commission encourages public- and private-sector payers to reframe their reimbursement policies to better support and widely implement EBPs.

The Commission urges the Centers for Medicare and Medicaid Services (CMS) to provide technical assistance to States on how to effectively finance EBPs. This technical assistance should address financing strategies for:

  • EBPs in mental health care for adults who are supported with Medicaid funding, including those practices identified through the SAMHSA/Dartmouth project, such as:
  • Family psycho-education,
  • Integrated care of co-occurring mental and substance use disorders,
  • Personal illness management,
  • Supported employment,
  • Assertive community treatment, and
  • Medication management.165
  • EBPs, such as the Collaborative Care Model, for adults with mental illnesses who are seen in primary health care settings. (See the description in Goal 4.)

  • EBPs in mental health care for children who are supported with Medicaid funding, such as the clinical aspects of parent-child interaction therapy, multi-systemic therapy, functional family therapy, and treatment foster care.

In addition, the Commission urges CMS to continue to clarify and simplify the waiver process and other administrative processes to facilitate States' using waivers to develop evidence-based practices.

Successfully transforming the mental health system, hinges, in part, on better balancing fiscal resources to support using proven, evidence-based practices.

The Commission notes the particular difficulty of engaging consumers in any type of treatment or support services - including EBPs - after they are released from public institutions, such as hospitals, residential treatment centers, jails, or prisons. For many of these individuals, losing disability benefits when they leave these facilities represents a major barrier to engagement. During extended stays in these institutions, consumers may lose their enrollment, lose their eligibility, or have their eligibility suspended from various disability income programs and from Medicaid or Medicare. When this occurs because rules and regulations have not been properly applied, it reflects confusion or misunderstanding of the rules and regulations. The Commission encourages CMS to collaborate with the Social Security Administration (SSA), the Veterans Administration (VA), and other relevant Federal agencies to clarify existing policy on reinstating disability benefit eligibility - and to explore changing existing policy, as needed. This is critical to facilitate following-up and engaging individuals in treatment and services after they are discharged from public institutions.

The Commission urges SAMHSA to work with CMS to facilitate collaboration between State Mental Health Authorities and Single State Medicaid Agencies.


5.3 Improve and expand the workforce providing evidence-based mental health services and supports.

Address the Workforce Crisis in Mental Health Care

The mental health field must move forward as quickly and efficiently as possible to achieve a more competent and expanded workforce necessary to ensure the full opportunity for recovery, resiliency, and wellness for all Americans with mental illnesses.

Workforce issues are a complex blend of training, professional, organizational, and regulatory issues. Because of this intricacy, the field needs a comprehensive strategic plan to improve workforce recruitment, retention, diversity, and skills training. In fact, without such a plan, it will be difficult to achieve many of the Commission's other recommendations.

To develop this plan, HHS should initiate and coordinate a public-private partnership. The process should broadly include the many non-Federal stakeholders, as modeled by several national groups that are already addressing workforce issues, for example, the Annapolis Coalition on Behavioral Health Workforce Education and the Coalition for Human Resource Development within Systems of Care.

The planning process must address the full lifespan of people with mental illnesses, balancing attention to the specialized needs of children and families, young adolescents, those transitioning to adulthood, adults, and older adults. The plan should draw on the experience gained through previous initiatives to strengthen the workforce, such as the National Institute of Mental Health Staff College, and on efforts to develop model curricula and interdisciplinary training programs. Also, the plan must facilitate its adoption by accrediting and licensing professional organizations.

The plan itself must include strategies to address the severe shortage of practitioners in the mental health workforce. In addition to addressing the workforce crisis within the formal mental health system, the plan must attend to training caregivers in other systems that provide mental health services, including the primary health care system, the corrections system, and schools.

The mental health field needs a comprehensive strategic plan to improve workforce recruitment, retention, diversity, and skills training.

Every mental health education and training program in the Nation should voluntarily assess the extent to which it:

  • Teaches evidence-based approaches to practice;

  • Uses teaching methods that have been demonstrated to be effective;

  • Offers a curriculum that incorporates the competencies that are essential to practice in contemporary health systems;

  • Builds skills in treating people with co-occurring mental and addictive disorders;

  • Educates consumers, families, and providers about mental illnesses and about the concepts of recovery and resiliency;

  • Engages consumers and families as educators of other health care providers;

  • Emphasizes developing cultural competence in clinical practice;

  • Ensures that the diversity of the community is reflected among trainees and in the training experience; and

  • Prepares students and trainees to work in interdisciplinary environments.

HHS must partner with State agencies that are responsible for the mental health care of children and adults to develop model, portable curricula to train direct care staff in the Nation's public-sector systems. In the case of service systems for children and families, these curricula must recognize and accommodate a variety of settings and providers, such as social service agencies, schools, and primary care settings.

Some curricula must target individuals who do not have graduate training. Others should be focused on students in graduate training programs or in-service professionals, such as psychologists, psychiatrists, social workers and psychiatric nurses. All training curricula should clearly reflect the perspectives of consumers and families.

In addition, graduate and continuing education programs must train more mental health professionals in effective evidence-based and emerging best practices. The field must move what we know into what we do. This transformation may require special attention from administrators and policy-makers, as well as from accrediting, licensing, and professional organizations, that have enormous influence on shaping health and mental health workforce education.

The Commission recommends that HHS refine its approach to technology transfer in mental health to ensure that:

  • Knowledge is translated more rapidly into the content of training curricula,

  • These curricula employ teaching methods of demonstrated effectiveness, and

  • Knowledge about effective education, recruitment, and retention strategies inform all public and private efforts to translate science to services.

Graduate and continuing education programs must train more mental health professionals in effective evidence-based and emerging best practices.


5.4 Develop the knowledge base in four understudied areas: mental health disparities, long-term effects of medications, trauma, and acute care.

To transform the mental health system, the Commission has identified and highlighted the critical policy areas of:

  • Eliminating mental health disparities,

  • Assessing the long-term effects of medications,

  • Reducing the impact of trauma, and

  • Improving acute care.

Research in these understudied areas is essential to ultimately improve the quality of mental health treatments and services.

Study Disparities for Minorities in Mental Health

While many types of disparities exist in mental health care, American Indians, Alaskan Natives, African Americans, Asian Americans, Pacific Islanders, and Hispanic Americans bear a disproportionately high burden because they receive less care and poorer quality of care.1 Similarly, these groups are significantly under-represented in mental health research and mental health service delivery.1 (See Goal 3 for a related discussion.)

To address this discrepancy, the Commission recommends conducting studies to inform policy decisions and develop a comprehensive research program for minority mental health. In particular, the Commission urges HHS to further study:

  • Racial and ethnic minority populations in the areas of psychiatric epidemiology,

  • Evidence-based treatment,

  • Psychopharmacology,

  • Ethnic- and culture-specific therapeutic interventions,

  • Diagnosis and assessment,

  • Prevention of mental illnesses, and

  • Promotion of mental health.

To close the gap that exists in the quality and access of care, the Commission also encourages researchers and grant-makers to focus on the impact of cultural competence on mental health treatment outcomes. Services research should focus on eliminating disparities in access to quality care among racial and ethnic groups.

Study the Effects of Long-term Medication Use

Since many psychotropic medications are treatments and not cures, some individuals with chronic illnesses, including children, must use them on a long-term basis. Current knowledge of their long-term clinical and economic effects is limited and must be expanded. With that goal in mind, the Commission recommends that NIH, undertake a sustained program of research on the long-term positive and negative effects of psychotropic medications for maintenance treatment of mental disorders - including children with serious emotional disturbances.

NIH and the U.S. Food and Drug Administration (FDA) should also provide information to educate consumers on the efficacy, effectiveness, and limitations of psychotropic medications. This research and information should apply to all age groups and special populations, particularly emphasizing the impact of long-term psychotropic medication use for children.

Examine the Effects of Trauma

The Commission recommends that HHS, through NIH, undertake a sustained program of research on the impact of trauma on the mental health of specific populations, such as women, children, and the victims of violent crime, including victims of terrorism. In addition, the Commission recommends that NIH and SAMHSA partner to enhance the evidence base and to evaluate service models for treating post traumatic stress disorder and other trauma-related disorders in public mental health settings.

Address the Problems of Acute Care

While the Commission's focus remains on full community integration for people with mental illnesses across the lifespan, available and effective acute inpatient and other short-term, 24-hour services are essential components of a balanced system of mental health care - especially for those in crisis who need the safety and intensive treatment in such settings.

The Commission recommends that HHS take the lead in:

  • Synthesizing the acute care knowledge base,

  • Reviewing the many outstanding model programs for acute care that already exist,

  • Developing new knowledge as necessary,

  • Assessing existing capacities and shortages, and

  • Proposing workable solutions to enhance delivering acute care and crisis intervention service.