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Abstract

Alternative crisis mental health responses are models that differ from the default, policy-only model of responding to emergency reports of acute psychological distress in the community. The two prevalent alternative models are co-response, pairing police with a civilian (such as a nurse or social worker) and civilian response, whereby first responders are not police. Two scoping reviews have been completed that synthesize key processes from the literature that underpin co-response and civilian response. Informed by transformative justice and the principle of the collective, this protocol details a knowledge-to-action (KTA) study whereby summaries of those scoping reviews will be used as prompts for semi-structured interviews with interest-holders (frontline service providers, people with lived experience of mental health crises, policymakers, and mental health scholars and advocates) across the United States and Canada. Interviews will focus on participants’ experiences with and perceptions of crisis response, as well as their opinions about the accuracy and relevance of the scoping reviews. The analytic plan incorporates content analysis and interpretive phenomenology to capture both the patterns that emerge and the meanings that participants attach to their experiences, producing a more layered and comprehensive analysis than either method could achieve alone. This protocol represents one of the first research plans to apply the KTA cycle and the first known study to propose that a team of researchers first synthesize the literature and then interview key informants about the accuracy and applicability of those knowledge syntheses. Findings may highlight discrepancies between the literature and the field, with a focus on alternative crisis mental health response.

Keywords

crisis mental health knowledge to action transformative justice content analysis interpretive phenomenology

Introduction

Across Canada and the United States, crisis mental health response – defined here as emergency interventions to acute psychological distress – is predominantly treated as a policing matter (Jackson & Bradford, 2019; Koziarski, 2018; Pepler & Barber, 2021). Such positioning reflects a convergence of longstanding systemic biases (Haag, 2022; Liegghio, 2013; Maynard, 2017; Poole & Ward, 2013) and structural shifts in mental healthcare (Ben-Moshe, 2020; Sealy & Whitehead, 2004; Shimrat, 2013). Logics rooted in Western colonial beliefs (Yee, 2022) and anti-Black racism (Maynard, 2017; Meerai et al., 2016) have long shaped the perception of people in psychological distress as dangerous, unpredictable, and/or criminal (Livingston, 2016; Livingston & Chambers, 2024). These logics deny distress as an expression of suffering or unmet needs, instead treating it as a public safety threat (Haag, 2022; Iacobucci, 2014). In doing so, they legitimize police-led interventions and embed criminalization and surveillance into the management of crisis, disproportionately targeting Black, Indigenous, and other marginalized communities (Black & Calhoun, 2022; Cotton & Coleman, 2010; Livingston & Chambers, 2024; Shore, 2015). The role of police in crisis response was reinforced by the deinstitutionalization movement of the 1960s, which closed large psychiatric institutions and transferred responsibility for care to the community (Ben-Moshe, 2020; Livingston & Chambers, 2024). Although deinstitutionalization was intended to promote community integration of mental healthcare, it was not accompanied by adequate investment in social infrastructure such as housing, social supports, or accessible healthcare services (Ben-Moshe, 2020; Livingston & Chambers, 2024). The absence of these resources left many without meaningful supports, rendering law enforcement, rather than health or social systems, the default first responders for individuals in crisis (Ben-Moshe, 2020; Livingston & Chambers, 2024). Systemic biases that criminalize distress and structural gaps in community care created the conditions in which police became the primary crisis response system. Over time, this reliance has become normalized, positioning law enforcement as central to mental health crisis response despite repeated evidence of harmful consequences. Therefore, it is commonly accepted that “traditional” crisis mental health responses posit police as first responders with outcomes including: police transport to hospital emergency rooms, justice system initiation (e.g., arrest, order), and/or behavioral de-escalation techniques.

Alternative Crisis Mental Health Responses

In response to growing public concern regarding the role of police in crisis mental health response and adverse – including lethal – outcomes during police-led crisis interventions (Marcoux & Nicholson, 2018; Singh, 2020), “alternative” crisis response models have been developed in the form of co-responder and civilian-led teams (Eaton et al., 2025; Livingston & Chambers, 2024; Rowe et al., 2025). These two models are alternatives to police-only response and represent distinct pathways for restructuring crisis response. The co-responder models pair police officers with other crisis response personnel, such as social workers and/or nurses (Eaton et al., 2025). The civilian-led model is a more recent crisis response approach that removes police from first response and dispatches unarmed responders, such as teams of clinicians and/or trained peers (Livingston & Chambers, 2024; Rowe et al., 2025).

The Present Study

This protocol outlines Phase 2 of a two-part knowledge-to-action (KTA) study on restructuring crisis mental health response in the form of co-responder and civilian-led teams. In Phase 1 (“knowledge”), we completed two scoping reviews that synthesized existing research and grey literature on the key processes involved in restructuring crisis response models into co-responder (Eaton et al., 2025) and civilian-led (Rowe et al., 2025) teams. Phase 1 provided a synthesized knowledge base that mapped the processes through which alternative crisis response models have been developed and highlighted the structural and contextual factors shaping their implementation. Phase 2 (“action”), described in this protocol, builds on those findings by engaging key informants to examine how the identified restructuring processes are understood and experienced in practice.

Objectives

This protocol is guided by four objectives: (1) To explore how key informants interpret and respond to the restructuring processes identified in Phase 1, including how these processes are experienced in practice; (2) To examine how key informant perspectives align with, misalign with, or extend the synthesized knowledge from the scoping reviews; (3) To identify perceived best practices, challenges, and opportunities for restructuring crisis response, with particular attention to concepts of safety, risk, and violence; and (4) To generate actionable insights to guide the future development, scaling, and sustainability of alternative crisis response models.

Theoretical Orientation

This protocol is theoretically guided by transformative justice (maree Brown, 2020; Ritchie, 2023), a framework for systems change that seeks to reduce reliance on punitive institutions while simultaneously building new infrastructures of care. Rather than focusing on reforming existing practices, transformative justice emphasizes taking concrete steps such as reallocating resources and expanding community-led supports that gradually rebuild and transform the broader care ecosystem (Ritchie, 2023). Applied to crisis mental health response, a transformative justice orientation highlights the importance of both recognizing the harms of police-led interventions and supporting the emergence of alternative models that can meet immediate needs while contributing to longer-term systemic change.

Central to transformative justice is the principle of the collective, which refers to the understanding that sustainable systems change must be shaped by the people most directly affected, together with those who play important roles in delivering and shaping services (Barrie, 2020). In crisis response, this means prioritizing the perspectives of service users, while also engaging frontline providers, peer workers, policymakers, and critical scholars whose work influences how these systems take form. The current study reflects this principle by inviting a range of key informants to engage with previous findings (i.e., knowledge from Phase 1) on alternative crisis response models, generating dialogue on their perspectives based on lived and/or professional experience. By grounding the study in transformative justice and the principle of the collective, the current protocol positions key informant perspectives as essential for translating synthesized knowledge into actionable guidance for the future of crisis response.

Methods

Study Design

The current protocol outlines a qualitative study guided by the KTA framework (Graham et al., 2006; Graham & Tetroe, 2010) and informed by transformative justice (maree brown, 2020; Ritchie, 2023). The study is situated within the “action” stage of the cycle, moving from knowledge synthesis into applied key informant engagement. Semi-structured interviews will be used to elicit reflections from diverse key informants on the processes identified in the reviews, focusing on their perspectives of the findings and insights from their experiences. This design was chosen to generate in-depth, contextualized accounts that can illuminate both the practical realities and broader implications of restructuring crisis mental health response.

Sample

Participants will include a diverse group of key informants who are engaged in, or critically analyze, crisis mental health response. Four categories of informants will be targeted, with flexibility in who is defined as a “key informant” to ensure anyone with experience and expertise in crisis mental health response has access to participating (1) Frontline service providers (e.g., clinicians, crisis workers, outreach staff, program managers) involved in co-responder or civilian-led teams; (2) People with lived experience of mental health crises and/or individuals who have previously accessed crisis support; (3) Policymakers and decision-makers involved in the design, funding, and/or governance of crisis response programs; (4) Abolitionist and critical mental health scholars, advocates, or professionals who study, critique, or mobilize around non-carceral alternatives. We anticipate interviewing approximately 40 participants in total, aiming for as even a distribution as possible across these four key groups. A sample of this size is expected to provide sufficient diversity of perspectives while remaining feasible for detailed, in-depth qualitative analysis. We will also seek geographic balance across participants from Canada and the United States. While all groups are important to the study aims, we expect service providers to be overrepresented given their greater accessibility through organizational and professional networks.

Recruitment

Recruitment is currently underway using a combination of purposive and snowball sampling strategies. For purposive recruitment, we developed a comprehensive spreadsheet mapping co-responder and civilian-led crisis response teams across Canada and the United States, as well as abolitionist advocates and scholars, and community-based crisis support organizations (including anti-carceral initiatives). This spreadsheet was created using data from existing sources (Law Enforcement Action Partnership, 2025), as well as information gathered through internet searches and the research team’s knowledge. Publicly available contact information was recorded for each organization or individual. Recruitment emails including a letter of intent and recruitment poster were distributed to identified contacts, inviting individuals to contact the research team directly to arrange participation. To extend recruitment reach, we are also using snowball sampling by asking participants and organizational contacts to distribute the recruitment poster through their professional and community networks. This approach is intended to facilitate the inclusion of participants who may not have been captured in the initial targeted recruitment process.

Data Collection

Data will be collected through semi-structured interviews, each approximately 60 minutes in length, conducted virtually via Microsoft Teams to facilitate participation across Canada and the United States. As part of the participation process, participants will first be asked to review a two-page plain-language summary of the Phase 1 scoping review findings (see Supplemental File 1), which is expected to take up to 60 minutes. The summary highlights the key processes in restructuring crisis response into co-responder and civilian-led models and will be sent to participants at least one week prior to their scheduled interview to allow time for review and reflection. This step engages participants in the KTA cycle by inviting them to consider synthesized knowledge before sharing their perspectives. The interviews will complement this preparatory step and will use an interview guide developed from Phase 1 findings, structured to elicit participants’ interpretations and perspectives. Additional prompts invite participants to reflect on best practices, challenges, and opportunities for system change. The interview guide was co-developed with our community partner at the Canadian Mental Health Association (CMHA) to ensure clarity, relevance, and sensitivity to the diverse range of participants. This collaboration helped balance research objectives with practical insight to ensure the guide would resonate with service providers and users, people with lived experience, policymakers, and scholars.

Data Analysis

Our analytic plan incorporates two complementary strategies: content analysis (Elo & Kyngäs, 2008; Hsieh & Shannon, 2005) and interpretive phenomenological analysis (IPA; Smith et al., 2009). We propose this dual approach because each method addresses a distinct analytic aim. Content analysis enables us to assess how participant perspectives align with or misalign with the evidence synthesized in our Phase 1 scoping reviews, offering a systematic way to map consistencies with and departures from existing knowledge (Elo & Kyngäs, 2008; Hsieh & Shannon, 2005). IPA, in contrast, provides a way to attend to the experiential and interpretive aspects of participants’ accounts (Smith et al., 2009), allowing us to explore how individuals make sense of crisis response in relation to fear, safety, and risk. By combining these approaches, we seek to capture both the patterns that emerge and the meanings that participants attach to their experiences, producing a more layered and comprehensive analysis than either method could achieve alone.

Content analysis is a qualitative research method used to systematically describe and interpret verbatim interview transcripts by identifying patterns, categories, and themes (Elo & Kyngäs, 2008; Hsieh & Shannon, 2005). It is particularly well suited to organizing complex narratives into structured representations of the phenomenon under study while remaining sensitive to context (Hsieh & Shannon, 2005). In this study, we will use a directed content analysis approach (Hsieh & Shannon, 2005). Deductive categories from the knowledge base drawn from our scoping reviews (e.g., interprofessional collaboration, piloting and evaluation, social and political will) will serve as sensitizing concepts to structure the initial coding framework. Consistent with Elo and Kyngäs (2008), we will also remain attentive to inductive insights by coding data that do not fit predefined categories, allowing unanticipated findings to emerge. Coding will be iterative and conducted in multiple cycles by multiple coders. Descriptive codes will first be applied to transcript segments, followed by grouping and refinement into broader categories and subcategories (Elo & Kyngäs, 2008; Hsieh & Shannon, 2005). Coding disagreements will be reported and resolved through coder meetings and independent analysis of the same datapoints. Constant comparison and analytic memoing will support rigor and transparency, with the goal of producing an account of how participant perspectives demonstrate alignment, misalignment, or expansion in relation to the knowledge synthesized in Phase 1.

IPA will be used alongside content analysis to explore the phenomenological dimensions of participants’ experiences and interpretations. IPA is an idiographic and phenomenological approach that seeks to understand how individuals make sense of significant and often emotionally charged experiences (Smith et al., 2009). It emphasizes participants’ lived experiences and researchers’ interpretive role in making sense of those accounts (Smith et al., 2009). This approach is particularly well suited to our study aims, as it enables close examination of how participants conceptualize crisis response practices. In this study, IPA will be applied to investigate how different participant groups (e.g., service providers, service users, people with lived experience, abolitionist and critical scholars) construct meaning around what constitutes “best practice” in crisis intervention. Attention will be paid to how participants describe and interpret feelings of fear, notions of safety, and perceptions of risk, and how these meanings are shaped by their positionality within crisis response.

Discussion

This protocol represents one of the first research plans to apply the KTA cycle and the first known study to propose that a team of researchers first synthesize the literature and then interview key informants about the accuracy and applicability of those knowledge syntheses. Conducting a study of this nature may highlight discrepancies between the literature and the field, commonly termed the “theory-to-practice gap” or “research-to-practice gap” (Greenway et al., 2019; Tkachenko et al., 2017). Therefore, this study may advance implementation science knowledge by illuminating reasons for time lags (Morris et al., 2011; Proctor et al., 2023) in between scholarly development of alternative crisis response models and their uptake in the field.

This study is also among the first to propose an analysis combining two of the major qualitative approaches in content analysis and IPA. The prospect of integrating qualitative analytic frameworks is relatively new in practice, with recent studies combining critical realism with framework analysis (Mercier et al., 2023) and text mining with manual thematic analysis (Nordstrom et al., 2025). Longstanding qualitative research traditions support choosing one analytic framework, seeing the major approaches (e.g., ethnography, grounded theory, phenomenology) as incompatible with one another (Padgett, 2012; Teherani et al., 2015). While some worldviews may be difficult to reconcile (e.g., post-positivism and social constructivism view experience in fundamentally different ways), there may be some opportunities for theoretical alignment. From a pragmatic perspective, this protocol presents the notions that: (a) a content analysis will uncover the extent of alignment between the knowledge syntheses and participant perspectives; and (b) IPA will construct a life-world of participant experiences that capture the phenomenon of providing and/or advocating for alternative crisis mental health responses. Taken together, this integrative analysis may support a more comprehensive conceptualization than one of the analytic approaches utilized in isolation.

Ethics

This study poses minimal risks to participants, that the research team will strive to mitigate. Participants may feel discomfort during the interview, potentially if they feel their work is being criticized or if they are speaking about lived experience of crisis. Participation is voluntary and respondents will be informed that they can pause or stop the interview at any time with no consequence. A debriefing form (Supplemental File 2) will be provided to all participants at the end of the interview. There is a slight chance that potential participants will be familiar with one of the interviewers; in these cases, an alternate interviewer will be identified and paired with the participant. All interviews will be audio-recorded, transcribed verbatim, accuracy-checked, and anonymized prior to analysis. NVivo will support coding and data management. Reflexive memos will be maintained and the team will meet regularly to compare interpretations and refine coding frameworks. Data will be stored on secure, access-restricted servers in accordance with institutional ethics approval obtained from the University of Regina’s Research Ethics Board [REB #1453].

Rigor

The analytic process will involve iterative stages, including immersive reading of de-identified transcripts, detailed noting and open coding, and clustering codes into emergent themes within each case before moving on to the next. Member-checking will be utilized to assess credibility (Thomas & Magilvy, 2011) as participants will have the opportunity to review draft findings prior to their finalization and dissemination. Our community partner CMHA provided input into the initial design of the study and we have since begun partnerships with a trade union of mobile crisis responders and a policy institute that resources alternative crisis response teams. These community partners ground our work in local, immediate relevance. An audit trail describing the study’s purpose, methods, processes, and findings will be utilized for transparency (Bowen, 2009).

There are moderate risks of social desirability and reporting biases (Bergen & Labonté, 2020; van der Steen et al., 2019) as the research team are inquiring about the accuracy and applicability of their own knowledge syntheses. To mitigate social desirability bias, the interviewers separate themselves from the synthesized material by referring to, for example, “the literature” instead of “our research” (Bergen & Labonté, 2020). To mitigate reporting bias, content analysis will specifically be employed to illuminate negative cases or instances where participants disagree with the material synthesized in the scoping reviews (van der Steen et al., 2019).

Conclusion

This study protocol describes the use of the knowledge-to-action (KTA) framework to interview key informants about recent knowledge syntheses in the area of alternative crisis mental health responses. The combination of content analysis and IPA as well as the multiphase application of the KTA cycle may be useful to other qualitative researchers seeking to sequentially appraise the literature and conceptualize the field.

Supplemental Material

Supplemental Material - Alternative Crisis Mental Health Responses: Protocol for a Knowledge-To-Action Study

Supplemental Material for Alternative Crisis Mental Health Responses: Protocol for a Knowledge-To-Action Study by Andrew D. Eaton, Megan W. Rowe, Leyna Lowe, Allannah Nguyen, Claire Ryder, Amanda Mathew in International Journal of Qualitative Methods

Supplemental Material

Supplemental Material - Alternative Crisis Mental Health Responses: Protocol for a Knowledge-To-Action Study

Footnotes

Acknowledgements

Thank you to Chantal Abdel-Nour for graphic design of the supplemental materials.

ORCID iD

Andrew D. Eaton

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work is funded by an Insight Development Grant from the Government of Canada’s Social Sciences and Humanities Research Council (SSHRC #430-2024-00241).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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