Talking About Suicide

New: The Waking Up Alive house

 April 25, 2012

The resources for people in a suicidal crisis are often pretty bleak beyond a crisis line call. I was happy to hear about a new project called Waking Up Alive, which appears to be the first of its kind in the United States and one of a handful in the world.

Sabrina Strong, a suicide attempt survivor herself, is the executive director of the New Mexico-based project, which is modeled closely on the pioneering Maytree Respite Centre in London. Maytree has been open for more than a decade as a welcome alternative to emergency rooms and psychiatric wards. It was founded by a longtime member of the Samaritans, which is well known for its “befriending” approach with crisis callers. Think of “befriending” as “making them feel more normal.”

Essentially, both Waking Up Alive and Maytree are homes, normal-looking residential homes, where people seriously considering suicide can stay for up to five days and try to clear their minds. The homes are meant to be a calm environment, with volunteers available around the clock for company and support. People can also leave whenever they choose, which certainly isn’t the case with psych wards.

An outside evaluationof Maytree after its first three years can be found here. It found that 70 percent of Maytree’s 159 guests by then had at least one suicide attempt before arriving. The report has some touching details, including one man describing life as like driving down a two-lane road, with no exit or shoulder, stuck behind a truck and trying to reach a destination he could never see.

Here is another independent report on Maytree from last year. It not only discusses similar programs in Canada and Ireland, but it also talks about other alternative approaches in Norway and elsewhere.

But back to Waking Up Alive. Opening a respite home for suicidal people in the U.S. wasn’t easy. “We’re soooooo litigious here,” Sabrina says. “We’ve hit the point in this country where people are so afraid of doing the wrong thing for someone who’s suicidal that they say, ‘You’re going to the hospital,’ and that’s it. Nobody actually wants to help someone before they’re hospitalized.”

By the way, the Waking Up Alive service, like Maytree, is free. Not bad, considering how much money they’re paying to nervous insurers.

Sabrina can tell you more:

So, where did you get the idea for this project?

It’s sort of an idea a lot of people in the suicide prevention field have kicked around, creating an in-between option for people who are suicidal but not enough to be hospitalized _ because that’s the traditional answer. Not only does that model not work, because a lot of times hospitals will not take people who want to be there, but some people are forced to be there, and that’s really a dehumanizing experience for a lot of people. A lot of people in the field say, “There’s got to be something we can do, a safe place.” But they couldn’t quite figure out how to do it. There are a lot of moving parts to creating a program like this.

Out here, we’re just so frustrated by how emergency departments, the crisis intervention system, worked. It’s obviously broken. There’s not enough capacity to meet needs. The only option was the hospital, so people waited six to eight hours in a waiting room with people who were psychotic or obviously criminally insane, escorted by police. They spend so much time in the waiting room that they start thinking, “Maybe I’m not suicidal. Maybe I’ll just go home.” And if you don’t have health insurance, nobody wants to take you. A lot of people are falling through the cracks. There’s no place to go for the specific help they need that allows them to keep their dignity and sense of control and safety.

We knew we needed something. We had an idea that that something would be a residential option. It was more of a pipe dream. A lot of people had the same pipe dream. But the liability in this country is too horrifying to wrap their heads around. Definitely in this country, but also around the world, there’s almost a critical mass that people know we need this. They don’t necessarily know what “this” is, but something better. I don’t know if it’s the way people are talking about suicide now, or those people working hardcore in suicide prevention and knowing. Regardless, I found someone who had the idea and found out how to do it. That someone was Paddy Bazeley with the Maytree Respite Centre. She started the program in London. She came from the Samaritans, the UK crisis line, and did that for years. She kept hearing over and over, “If just I could go somewhere for a few days, I could work this out on my own.” I don’t know about you, but I tried that, but you tuck all of these problems in your suitcase and take them with you. You end up in a strange place, and the suicide risk is greater.

Her idea was to have a house, a residential house, a place where people can come and stay. It’s not going to be clinical, not going to be medical. They don’t even search people, which is not an option for us. Basically, the stay there is about five days. That came about through trial and error. People get enough of a break, enough solid time to think and reflect and bounce ideas off of people. At the same time, they’re not away from home too long. It’s not like going to rehab. They’ve been doing this, I think, for 11 years now. It’s successful, and a lot of people around the world are figuring out how to replicate it. As far as I know, we’re the first in the U.S.

Do you know of others outside the U.S.?

There’s one in Ireland. And I got an e-mail from a woman in the Netherlands, though it’s not exactly the same program. I just started getting e-mails from a woman in Australia, she has some kind of fellowship on how to replicate that crisis model in their country. And because Maytree is aware of us, they’ve started referring people to us.

Just as you’re starting it all!

I know. It’s pretty scary.

Have people arrived yet? How has that gone?

Yep. It works exactly the way we thought. The first guest came through a couple weeks ago. It was kind of a trial basis, to make adjustments. We explained up front to people exactly what to expect. Part of making these models work is always having someone make the hard policy decisions. Somebody decides, “This is how it’s going to be.” Paddy’s way is, they don’t search people, and a lot of people think that’s crazy. That’s not for us. We have gun ownership in this country, and a lot of guns in the Southwest. We can’t not search them.

Clinicians are looking for that, a program that has been thoughtful about the risks. That’s why we require a referral from a mental health clinician. We can’t just take everybody on their word, that they’re going to be OK. We expect people to have problems, and we want to make sure they’re not at such imminent risk to themselves that they need to be in the hospital. We’re actually trying to get people earlier in their crisis, before the choice isn’t theirs anymore.

We are very up front with people, so they’re not surprised. I remember that kind of experience being hospitalized. It was really frightening. Like, “OK, now we’re going to strip search you.” I was like, “How did I get to this point?” Like, oh my gosh, it’s just an experience not to repeat.

So people who come don’t have to worry about insurance. It’s all free, right?

Right. As long as we can manage to keep it free. We’ll open it up to people out of state, but they’ll have to pay. We’ve had people contact us, desperate. People are looking for anything. They’ll take anything. We have a teeny-tiny bit of funding, but we keep it reserved for people who live in this state.

How many people have come through?

So far, just the one. The word is still percolating. Clinicians are starting to contact us and ask us five million questions. They like what they’ve heard. They appreciate how well thought out it is. People appreciate that. Because we’re obviously shifting the liability to clinicians because they’re making the referral, they want to make sure nothing will come back on them. We’re soooooo litigious here. We’ve hit the point in this country where people are so afraid of doing the wrong thing for someone who’s suicidal that they say, “You’re going to the hospital,” and that’s it. Nobody actually wants to help someone before they’re hospitalized.

What’s so brave about you?

So yeah, everybody asked, “You’re really going to do it?” It cost us an arm and a leg and a firstborn just to insure the program. That’s why it took so long. We couldn’t get anybody to even entertain the idea. Once we pulled together the insurance quotes, it was outrageous. I was told that was to be  expected.

How much is the insurance?

About $7,000 a year. Not cheap.

I read over the Maytree site and how it works. Have you made any changes? Especially to the policies of no follow-up contact after a person leaves and the limit of having just one stay?

I want to. The follow-up piece is something you have to be incredibly thoughtful about, and find a way to pay for it. So I do follow-up phone calls, e-mails to collect data for grants, because people want to know, “Does it work?” I want to follow up after a week, a month and a year. To me, it’s not ethical to call someone once a year and ask, “Are you still alive?” and stick that in the win column. It also opens up a world of things when you ask someone, “How’s it going?” and hear “Life sucks” and you have an obligation to do something. I have a lot of ideas. But securing the core of the program is step one. You have to be thoughtful, because you’re opening up a huge can of worms when you ask, “How have you been?”

Also, we talked about that, not being able to come back. Most people in the mental health world understand that. You have what are called repeat offenders, who come back again and again and again. Who knows. They’re hungry and you feed them, or they’re homeless, or they’re really just miserable all the time. You end up finding out more and more about that person and their life and their illness, and we’re not equipped to do that. We deal with suicide, not with the disorder or the self-injury or whatever the diagnosis is, and the more contact there is, the more you have to know about that.

I never say never. Because some people are chronically suicidal, and they might not get the same benefit out of it, there are different conditions under which some people might be able to return. But it’s not a revolving door. We’re not here to be abused, but we don’t want some people to feel they can never come back. And actually, Maytree does the same thing. If there’s a circumstance that changes in that person’s life, they sometimes take people back. And they have taken people back.

In an early article in the UK press about Maytree, Paddy talked pretty straightforwardly about the possibility of having a death there. How do you address that?

Yes. They have 10 years of data on how it works. She said that we can expect people to kill themselves in the program _ or, excuse me, to try to kill themselves. They’ve never had a death. It’s a worst-case scenario we have to plan for. We tell volunteers, “You’re choosing to do this. You’re working with high-risk people, and at some point you’re going to lose somebody.” You’re playing the odds. They had one person go home and the next day kill themselves. It’s gonna happen. People are going to make what in their mind is an informed decision. All we can control is what happens here, to a certain extent. That’s why we search, and why we ask them not to bring more than seven days of medication.

People may try to kill themselves on site, but don’t I recommend it. We will have eyes on them every 15 minutes, if they’re talking, if they’re journaling. We’re prepared as much as we possibly can be. There were a handful of attempts at Maytree, every time an overdose, and every time the person thought better of it and went and told them. I tell people, “Just don’t freak out, OK?”

Talk a bit about your background, having attempted suicide yourself, and any concerns about how this work will affect you.

Yes. I was chronically suicidal for about a decade, in my late teens and 20s. It ended in a serious suicide attempt, and I spent four or five days in a locked psychiatric unit. It was a turning point. It got me to a point where I could finally get the help I needed. But at same time, it was such a long, drawn-out downward spiral that someone should have been able to step in at some point and say, “You need help. Let me help you.” How many years do you have to go through that before an intervention? It took a few years to even figure out how to talk about it, and taking that and being comfortable sharing that in a professional setting.

Any reasonable person would be nervous going into this. I talked with my therapist. He actually helped a little bit getting this project off the ground, and he knows what I’m doing. I know at some point something is going to happen. I tell people, “I don’t expect you to be superhuman. You will trip over your own baggage. I just want you to know it’s there. If something sets you off, we’re going to sit down and have a chat about that.” I think that’s the best you can hope for.

Did you plan and furnish the house yourself?

Yeah. We got a start-up grant to do what we needed. We got a lot of stuff donated. After that, we bought things here and there. We’re renting. We’ve been lucky enough to have people who sort of believed in us and helped us along the way.

Do you have your own favorite space in the house?

I like a lot of the spaces in here. We took a lot of care selecting things, just the right setup. Every sitting area, I really love. It’s a place where people want to sit and talk. That’s what Maytree is, a lot of tiny rooms with chairs to sit and talk.

Have you been to Maytree?


Professionally or personally?

I was on vacation, and we were at the point where we were kicking around the idea. I started Googling suicide prevention programs in the UK, and I said, “This is the thing. Someone’s actually done this.” I went and talked with Patty and got a tour of the house. It was pretty awesome. I asked her every question I could think of. The truth is, it’s a very simple model. If you don’t mess with it too much, it has a magic of its own. It’s a place where people are not going to freak out if you’re talking about suicide.

Did you have one big burning question for Patty?

It was more like, “How do we do this? What are the things that absolutely make this program what it is?” And she said, “It’s a program about talking. There’s really no structure to it. It’s really just talking and talking, and talking some more.” It’s not a place that’s a revolving door. It’s putting ownership on people where they have to make the most of their time. The last thing she said to me was, “My advice is, just do it. You’ll be surprised to find what will happen. You’ll be surprised at what kind of support you’re going to get.” And I did. Literally, I got home and I had a grant announcement in my in-box and I said, “I think we can get this.” And we got it. And I thought, “Oh my god, these people are as crazy as I am.” But people understand the need for it. They love we’re doing something _ we’re doing anything _ we’re doing something new and radical: “Wait, we’re the first one in the country, and we’re in Albuquerque?” Hey, it’s just happening. It’s just happening. And it’s been nonstop since.

It can be difficult finding people to support anything related to the topic of suicide. Would you like to thank anyone here?

OptumHealth of New Mexico, because they took a chance on us. They gave us every penny we asked for and said, “Go do it.” And our volunteers and staff, they’re kind of amazing. That anyone wants to do this amazes me. Obviously, the folks at Maytree, Patty was great. Hopefully we can pay it forward to help other places get off the ground. I didn’t realize how much of a big deal it would be not just here in the U.S., but internationally. Since we’re on the short list of places that got it off the ground.

Outside of this work and your experience, who else are you?

That could take forever to answer. I’m a lot of things. Just right now, this here’s one of the things taking up all my time. I know once we can get it off the ground, I can go back to having a life. Right now, this is where I want to be. I’m always doing something about some taboo topic that just makes my parents cringe: “What is she doing now?” I guess they’re probably happy I’m not doing safe sex education anymore.

Have they been by the house?

Oh yeah. My mom is a volunteer here. My dad actually is working overseas, but he did a few things cosmetically we needed done here.

Your mom is a volunteer!

I’m as surprised as anyone else.

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