Crisis resolution teams in Ireland

CRTs were introduced in Ireland in 2023 with the establishment of five pilot “learning sites,” in tandem with the launch of the HSE’s Model of Care (2023). These services provide intensive home- and community-based alternatives to hospital admission, with evaluation from these learning sites informing national rollout.

Each CRT operates through extended-hours teams providing rapid assessment and intensive, community-based support. Interventions are time-limited, with the Model of Care envisaging CRT involvement of up to six weeks to maintain capacity. In practice, some episodes may extend beyond this where complexity and limited onward pathways delay transfer back to referrers or onward services. Unlike other recent development programmes in Irish psychiatry, such as adult ADHD, eating disorders or early intervention in psychosis, CRTs serve adults over eighteen experiencing a mental health crisis regardless of diagnosis, reflecting the reality of crisis presentation. Thus these services are configured around this need rather than a disorder-specific pathway.

Several sites have introduced Solace Cafés, peer-led, non-clinical spaces operating evenings and weekends that provide immediate support, de-escalation, and signposting. This combination of clinical crisis teams and community cafés broadens crisis response options beyond traditional hospital-based care, potentially reducing emergency department presentations.

The elevated and increasing service utilisation of autistic adults with comorbid mental illness has already been observed amongst general adult mental health teams (Gilmore et al. Reference Gilmore, Krantz, Weaver and Hand2022, Zaleski et al. Reference Zaleski, Craig, Khan, Waber, Xin, Powers, Ramey, Verbrugge and Fernandez-Turner2025). However, the challenge for CRTs is distinct, where many acute crises present atypically, reflecting core autistic symptoms with persistent functional impairment compounded by additional stressors (Lai et al. Reference Lai, Kassee, Besney, Bonato, Hull, Mandy, Szatmari and Ameis2019, Rosen et al. Reference Rosen, Mazefsky, Vasa and Lerner2018). Autistic adults presenting to crisis care pathways reflect international experience, where they account for a disproportionate share of psychiatric crisis contacts globally, with elevated emergency department attendance and suicide risk (Vohra et al. Reference Vohra, Madhavan and Sambamoorthi2016). For this reason, crisis pathways become a common point of contact for autistic adults to specialist mental healthcare. For CRTs, this places the absence of integrated onward autism pathways into sharp relief, shaping both the acute episode and what follows.

Autism and psychiatric crisis: clinical realities

In our clinical experience, autism is frequently not apparent in referral documentation, and unconfirmed at the point of crisis contact. This often emerges in the course of CRT formulation, through history, self-identification, observation or collateral information. Accordingly, we understand autism to refer to both formally evaluated diagnoses and also autism identified through clinical formulation. In such cases, formulation can reveal a crisis arising from neurodevelopmental stressors. Such acute crises often reflect “autistic burnout”, the cumulative effect of sustained social demands, sensory overload, and the exhaustion of coping strategies (Raymaker et al. Reference Raymaker, Teo, Steckler, Lentz, Scharer, Delos Santos, Kapp, Hunter, Joyce and Nicolaidis2020). Such presentations may resemble depression or severe anxiety, but their trajectory is often distinct: functional deterioration, withdrawal, and loss of daily capacity rather than discrete psychiatric episodes (Arnold et al. Reference Arnold, Higgins, Weise, Desai, Pellicano and Trollor2023; Raymaker et al. Reference Raymaker, Teo, Steckler, Lentz, Scharer, Delos Santos, Kapp, Hunter, Joyce and Nicolaidis2020). Such episodes frequently recur in the absence of environmental adaptation and continuity.

Suicidality is among the most common points of contact with psychiatric services, yet in autism the risk profile often differs, with crises driven by chronic stress, social exclusion, and unmet support needs rather than depressive illness. Kato et al. (Reference Kato, Mikami, Akama, Yamada, Maehara, Kimoto, Sato, Takahashi, Fukushima, Ichimura and Matsumoto2013) found autistic individuals over-represented amongst those who attempt suicide, often with adjustment disorders rather than major mental illness, using more lethal methods suggesting this pattern was linked to impulsivity and cognitive rigidity. Transitional periods such as moving to higher education or employment are particularly hazardous, often triggering first psychiatric presentations, as cumulative vulnerability exceeds coping capacity (Lake et al., Reference Lake, Perry and Lunsky2014). These presentations likely contribute to disproportionate crisis pathway contact among autistic adults. Brief interventions can stabilise acute distress, however preventing recurrence often depends on continuity and onward supports beyond the crisis episode.

The burden of suicidality is marked. Cassidy and colleagues (Reference Cassidy, Bradley, Robinson, Allison, McHugh and Baron-Cohen2014, Reference Cassidy, Bradley, Shaw and Baron-Cohen2018) found lifetime suicidal ideation in nearly two-thirds of adults with Asperger syndrome, with both formal diagnosis and self-reported autistic traits independently increasing risk. Camm-Crosbie et al., (Reference Camm-Crosbie, Bradley, Shaw, Baron-Cohen and Cassidy2019) confirmed these elevated rates, while systematic reviews document increased suicide deaths across the spectrum (Zahid and Upthegrove Reference Zahid and Upthegrove2017). It is likely consequent to this combination of higher risk of suicidality but without the presence of major mental illness, that these individuals are more likely to find themselves referred to a CRT rather than a general adult mental health service.

International evidence reveals a troubling pattern; autistic adults frequently use crisis services yet find them poorly suited. They present more often to emergency departments, re-attend sooner after discharge, and face prolonged admissions when community supports are absent (Lunsky et al. Reference Lunsky, Weiss, Paquette-Smith, Durbin, Tint, Palucka and Bradley2017; Vohra et al. Reference Vohra, Madhavan and Sambamoorthi2016). Services can inadvertently compound distress through sensory environments, communication mismatches, and limited staff autism training (Doherty et al. Reference Doherty, Neilson, O’Sullivan, Carravallah, Johnson, Cullen and Shaw2022; Sadatsafavi et al. Reference Sadatsafavi, Vanable, DeGuzman and Sochor2023).

Despite clear guidance favouring autism-informed communication, environmental adaptation, and structured psychosocial interventions as first-line approaches (Allahdad et al. Reference Allahdad, Gluyas, Spain, Blainey, Doswell and Onyejiaka2024; Guinchat et al. Reference Guinchat, Cravero, Lefèvre-Utile and Cohen2020), reserving medication for clear psychiatric comorbidity, implementation remains patchy. NICE emphasises 24-hour crisis planning and proactive support (NICE 2012), yet such provisions rarely exist. Consequently, autistic adults enter psychiatric services only after crises escalate beyond family capacity, creating cycles that strain services while leaving needs unmet.

Experience from our CRT learning site illustrates that autistic adults present frequently with acute risk, including suicidality, severe functional deterioration or escalating distress, requiring autism-informed adaptations to assessment and communication. While the Model of Care emphasises that CRTs should not fill wider service gaps, limited onward pathways can in practice lead to repeated re-presentations, delayed transfer, and recurrent “holding” contacts around the same unresolved needs. Consequently, CRTs are vulnerable to filling in the gaps in services without the comprehensive support required to prevent recurrent crises. Thus CRT clinicians must balance system-level constraints with the reality of service provision, recognising when presentations reflect autism-related stressors while also assessing carefully for comorbid psychiatric illness.

Towards autism-informed crisis care

These gaps highlight a cohort whose needs have long been underestimated in mental health service design. Autistic adults without intellectual disability, the “missing middle”, are functionally independent, yet acutely vulnerable to crisis. In our clinical practice, care must proceed on a needs-led basis, usually without access to structured diagnostic assessment. This presents a significant challenge for CRTs. When no onward pathway can hold longer-term formulation and follow-through, support can default to a series of poorly connected crisis contacts across services such as emergency departments, crisis teams, primary care and community services. This entails repeated handovers and repeated “starting again.”

Such presentations highlight the need for adaptation at a broader system level. As Lake et al. (Reference Lake, Perry and Lunsky2014) and Maddox et al. (Reference Maddox, Crabbe, Beidas, Brookman-Frazee, Cannuscio, Miller, Nicolaidis and Mandell2020) observed, mainstream services frequently fail to account for this group, who are neither eligible for disability support nor well served by standard psychiatric pathways. We offer recommendations to address this gap.

Firstly, workforce capacity is critical. When autistic adults present in acute crisis, staff competence in autism-informed care often determines whether situations escalate or resolve. Clinicians consistently report lacking confidence in communicating with autistic service users, adapting environments, or formulating suicide risk (Camm-Crosbie et al. Reference Camm-Crosbie, Bradley, Shaw, Baron-Cohen and Cassidy2019; Greenwood et al. Reference Greenwood, Cooklin, Barbaro and Miller2024). International surveys confirm that these barriers drive disengagement and negative experiences (Doherty et al. Reference Doherty, Neilson, O’Sullivan, Carravallah, Johnson, Cullen and Shaw2022). The “double empathy problem”, mutual misunderstanding between autistic and non-autistic people, becomes particularly acute in crisis settings (Milton Reference Milton2012). In high-stakes environments, communication misalignment can rapidly escalate distress. The HSE’s National Clinical Programme for Self-Harm and Suicide (Health Service Executive 2022) states all staff carrying out assessments on people with suicide related ideation and self-harm should receive training in understanding autism, be attendant to the potential for co-occurring psychiatric disorders, and know how to best communicate with and support autistic people with self-harm or suicidal ideation. Realising this requires a coordinated approach to skills building, and CRTs offer an opportunity to embed autism-informed training as a core competency for frontline staff.

Secondly, proactive crisis planning represents a crucial opportunity. The creation of a care and safety plan is the mainstay of CRT intervention, framing therapeutic interventions. Care plans aim to be recovery-focused and highlight relapse prevention strategies (Health Service Executive 2023). While CRT care planning is individualised and collaborative, autism-informed crisis planning depends on autism being recognised during formulation and on access to neurodevelopmental specific approaches. As CRTs are generalist crisis services there is a risk that these elements can be missed unless actively elicited and supported. NICE (2012) has long recommended personalised crisis management plans, developed collaboratively with autistic individuals and families. An achievable aim for CRTs is to embed autism-informed elements within routine care and safety planning, supported by training and specialist consultation, so that short-term intervention becomes a bridge toward greater stability and safer follow-up.

Thirdly, CRTs must maintain clear boundaries. Without appropriate onward care pathways, services risk drifting into long-term case management for autistic adults, diluting their remit as intensive, short-term alternatives to admission. This is particularly important given the breadth of crises CRTs respond to across diverse clinical and social contexts. As diagnosis-agnostic services, CRT effectiveness depends on onward pathways that can advance recovery and reduce recurrent crises; these are well developed for many drivers of crisis, for example addiction services, social and housing support and CMHT care for enduring mental illness, but remain limited for autistic adults without significant intellectual disability. This supports the need for distinct adult autism teams, accessible to both CMHTs and CRTs.

There is experience to draw on, such as the Transforming Care in Autism pilot in London which placed a specialist autism crisis team working alongside general adult services, providing consultation, training, and joint working rather than duplicating or replacing existing provision (Allahdad et al. Reference Allahdad, Gluyas, Spain, Blainey, Doswell and Onyejiaka2024). This is already called for in the Autism Innovation Strategy (2024), which calls for shared-care approaches to ensure continuity across services. Specialist autism services are essential to provide inclusive, equitable support for autistic people, particularly those with vulnerabilities and increased risk of suicide (Department of Children, Disability and Equality 2024). Ultimately the needed development of such services in Ireland will have a remit that extends well beyond crisis prevention, and yet improved crisis prevention may be an important early dividend. Such onward pathways will allow CRTs to continue to provide responsive, time-limited work, consistent with what they were designed to do.

Fourth, crises in autistic adults rarely stem from psychiatric issues alone but emerge from intersections with education, employment, housing, and social care. Yet this cross-domain complexity has paradoxically meant that overall responsibility falls to no one. As Maddox et al. (Reference Maddox, Crabbe, Beidas, Brookman-Frazee, Cannuscio, Miller, Nicolaidis and Mandell2020) observed, autistic adults are often bounced between systems, turned away from mental health services when difficulties are seen as sequelae of autism, yet not meeting criteria for disability services, creating dangerous responsibility voids. Ireland’s Sharing the Vision: A Mental Health Policy for Everyone Implementation Plan 2025–2027 (Department of Health 2025) prioritises better integration and seamless transition between services with clear governance of referral pathways to support continuity of care. Within this plan sits the National Autism Protocol, which while currently framed around assessment and early intervention for children and young people, signals the wider policy intent towards more integrated services pathways. This policy, whilst aiming to improve access to timely, effective autism centred care, has been met with concerns (Psychological Society of Ireland 2024) underscoring the need for transparent governance aligned with professional standards. This reinforces that real integration will depend on cross-sector governance that clarifies clinical ownership and creates linked pathways, rather than leaving recurrent autistic crises to be managed at the interface between services. This would benefit not only autistic crises but longer-term autism needs.

Finally, involving autistic people and families in service design is critical. Service-user involvement from inception has been a strength of the CRT model. As pilot sites generate learning, ongoing review should include autistic adults’ lived experience specifically to inform iterative refinements of CRT models at scale. As Nicolaidis et al. (Reference Nicolaidis, Raymaker, Ashkenazy, McDonald, Dern, Baggs, Kapp, Weiner and Boisclair2015) identified, autism related patient-level factors influence the success of such a service from a practical perspective which can only be obtained from the patients themselves. Their involvement in evaluation and development ensures CRT evolves with service user needs remaining at its core. This could entail co-production approaches such as a standing lived experience advisory group. Embedding qualitative and quantitative service user feedback at the end of crisis service engagement would provide an accessible and representative voice. Practical involvement of service users in reviews, training and reflective practice would also provide a formal feedback loop for CRT development.

Together, these changes would enable CRT to contribute to system-wide improvements for autistic adults, a group whose complex needs already feature prominently in crisis services.