By Jennifer L. Tirado, Moodfuel
Discover the unique approach of Alternatives to Suicide, a peer support program offering a safe space for discussing suicidal thoughts without coercion or judgment
It was an overcast September evening when Danny* (not this person's real name) joined our Wednesday support group at a drop-in center. The space was wide and resembled a living room. In the middle, two full couches and Ikea-style, mauve loveseats created a comfortable circle.
Danny, who used they/them pronouns, entered with hands shoved deep in the pockets of a navy blue Northface jacket. Their lean frame towered over mine for a moment until they sat opposite me on one of the large couches.
It didn't take long for Danny to confess they were headed to a bridge known for jumpers. While they waited for the usual response – physical hands on, probing questions about means and access, a rapid call to 988 – we continued to sit and listen calmly.
We expressed curiosity about what was going on in Danny’s life that led them to this decision. The end of a romantic relationship and abandonment, not just by shared friends, but by a whole community – so much loss, all at the same time! The despair borne from their isolation made sense to us and we said so.
Group members related to parts of Danny’s story, and we shared our own accounts about the personal impacts of ended relationships. We all had felt deep pain during those times, too.
I don't know what happened after our meeting, but I like to think Danny drove home and felt calmer, a bit better, because toward the end of the meeting, they laughed with us, saying this was the first time they had felt comfortable so openly expressing such feelings. Leaving, they did seem to appear lighter, the world no longer on their back.
I hope if Danny entered that dark place again, they would return to our group to experience more curious, shared acceptance and open, nonjudgmental discussion.
Does our group sound unusual? It is unique because every participant has personally experienced wrestling with thoughts of suicide, in the past or present. It's one of the only requirements for joining, especially for facilitators like me.
Not only have I facilitated many support groups, like the one Danny visited, over the last several years, I also was the first Statewide Alternatives to Suicide Coordinator for two years in Connecticut. In this role, I hired and trained facilitators and established support groups in every part of the state.
I'm part of the Wildflower Alliance training team, working with group facilitators in-person and online, in different states and different parts of the world.
Many of the people who attend our groups have experienced the psychiatric system. A good number of us receive therapy. Ironically though, we've learned that suicide isn’t a topic we can discuss in a therapist’s office, even the ones with whom we have good relationships. We know we could be “involuntarily held.”
In more common suicide prevention programs, such as ASIST and Question Persuade Refer, the emphasis is on stopping a distressed person by any means necessary from taking their life. There is great reliance on forced interventions, crisis teams, hospital commitments and evaluations. Little attention is paid to discovering the underlying roots of the distress.
Scientists have found that this carceral approach frightens and frustrates many, especially trauma survivors. Sometimes these measures can intensify tenuous situations and lead to more harm, even the death, of someone who sought help from a stigmatizing system.
According to research published in the International Journal of Law and Psychiatry, “A lack of communication and a power imbalance among the stakeholders hindered respect for the service users' rights, will, and preferences. This was exacerbated by professionals rationalizing coercion and assuming that service users were incapable of understanding information.”
Suicide prevention meets Harm Reduction
The groups I formed and facilitated are part of the Alternatives to Suicide (Alt2Su) program. It's a philosophy and training created at the Wildflower Alliance and it's very different.
Our goal is not to stop a person from considering suicide, but to have an open and empathic conversation from a peer perspective about what’s going on for them. Alt2Su uses the principles of Harm Reduction coupled with the power of peer specialists to support people who struggle with suicidal thoughts and attempts.
While Harm Reduction is mostly known in the context of addiction, it can be applied much more broadly, and our society is full of examples.
In the context of Alt2Su, Harm Reduction emphasizes letting go of coercion and fear as the basis for addressing suicidal thoughts. Instead, we support a person while they struggle to create meaning for themselves and connection on their own terms – the same process we as peers went or are going through.
Fundamentally in Alt2Su, reducing harm is always up to the individual with consent as a key value. So, not only is the broad usefulness of harm reduction such a powerful ingredient, but lack of coercion or force, the development of self agency and the peer perspective are essential.
In addition, Alt2Su uses Harm Reduction Dialogue, a method that highlights strategies for how to speak effectively with someone who is struggling. It supports the person's mental distress and honors their autonomy – without any hidden agenda from facilitators.
The usual response
Before I knew anything about Alt2Su, I reached out for help because I was hurting myself and felt afraid. What a mistake.
After being subjected to the same emergency response and uncomfortably probing questions Danny worried about, I was funneled through the healthcare system. One “warm handoff” led to another and another, until I was forced into a psychiatric lockdown unit for a week – no cell phone, no access to the outside world.
In most of the country, this is "treatment." While I'm aware that some people sign themselves in to this type of environment willingly – I've done that, too – it's time for a more critical appraisal of this process.
In Alt2Su trainings, we discuss some statistics.
- Assessments: According to a 2016 press release by the American Psychological Association, Harvard professor, Joseph Franklin found that assessments are no better at predicting someone's suicide risk than flipping a coin.
- Forced treatment: Research shows that forced treatment can elevate the risk of suicide
- After a review of 100 studies worldwide, the Journal of American Medicine Psychiatry concluded in June 2017, “The immediate post-discharge period is a time of marked risk, but rates of suicide remain high for many years after discharge."
- The June 2019 issue of the American Association of Suicidology's journal, Suicide and Life-Threatening Behavior, stated, “Patients’ perception of the context in which they were hospitalized is associated with a small but significant increase in their likelihood of post-discharge suicide attempts.”
The power of peers
Lived experience is what gives peer specialists, also known in Colorado as peer support workers or peer navigators, a unique distinction. While no two experiences are identical, the ability to relate from this place of visceral, personal understanding is rarely achievable with book knowledge alone.
Talking to someone who has similar battle scars is cathartic. It was part of the original ethos for groups like Alcoholics Anonymous and other 12-step programs focused on lived experience. While these groups emphasize abstinence, there is room for Harm Reduction as well, especially as it pertains to people who struggle with mental health crises.
In Alt2Su trainings, we often discuss the phrase, "by any means necessary." We put aside the clinical approach and expand its meaning to encompass a host of human needs, including all forms of meeting people where they are. Peers can do much to help fill these needs.
The public, the healthcare industry and policymakers can learn much from our stories and the ways we share them. Story sharing is one of the oldest human traditions, and also forms the heart and soul of peer support.
The capability of many and one
The efficacy of the Alt2Su approach is still under-researched, but at least one study shows promise. An extensive 2019 investigation by Curtin University School of Occupational Therapy, Social Work and Speech Pathology indicated that while peer support group attendance didn't eliminate suicidal thoughts for most participants, the communal aspect helped them relate to these thoughts and inclinations more constructively. Group members could better tolerate thoughts of suicide without acting on them, gained a degree of mastery over them and viewed the thoughts from a more emotionally empowered place.
Applying harm reduction to suicidal thoughts and attempts was the innovative idea of Executive Director Sera Davidow and others members of the Wildflower Alliance leadership team. Davidow also has lived experience with suicidality and carceral prevention.
“I have experienced forced hospitalization related to suicide, and more specifically, related to self-injury and suicide. I was very clear that this caused more harm than good,” Davidow said.
She added that the normalization of coercion and the stigma attached to questioning the status quo, initially prevented her from voicing her thoughts about systemic change.
“For a long time after, that wasn't a message I heard – 'the system caused harm,' and I didn't figure out how to talk about it myself for some years. I just knew it felt bad and yet somehow, I still mostly towed the line when I talked about ‘mental health’ …, but I never was honest again with anyone who had power over me about being suicidal, at least not until several years down the road.”
Davidow and her team started the first Alt2Su peer groups in 2009 in collaboration with Tapestry Health Systems, a harm reduction organization.
Harm Reduction in Colorado
Harm reduction has faced challenges in Colorado, mostly because policymakers only associate it with people who use drugs. Human services workers recognize clean needle exchanges and safe using sites, but the broader, daily definition hasn't been applied and it's not perceived as a public health need.
Colorado legislators tried to support traditional harm reduction efforts. Last year, state Democrats Elisabeth Epps in the House and Kevin Priola in the Senate sponsored HB24-1028 to bring overdose prevention centers to more cities, but their bill never made it out of the Health & Human Services Committee.
The good news is Colorado’s Department of Suicide Prevention (DSP) is no stranger to innovative thinking. According to Davidow, DSP funded multiple in-state trainings by the Wildflower Alliance, including a train-the-trainer program, for a Fort Collins organization, the Yarrow Collective.
“Learning about Alternatives to Suicide and actually being able to explore my relationship to my thoughts and feelings about suicidality has helped me understand that (for me) it was about a loss of autonomy and control in my life,” said Ashleigh Jones, training director and family services coordinator at Yarrow Collective.
“Now, I have been able to take back my experience. Instead of seeing it as something that was wrong with me or see myself as broken, now it’s actually a source of power,” Jones said.
As with Danny, Alt2Su group participants explore our most meaningful needs, ones that, if met, would keep us on the planet. Whether it be online, in a local library meeting space or at a rented art studio, when an Alt2Su group comes together, I can hear the sighs of relief.
It’s the one space in which we can talk about the stigmatized subject of suicide without judgment or fear of coercion. Participants receive a room full of recognition, validation and a sense of community. Isolation – if only for the 90 minute meeting – is replaced with human-to-human connection.
