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Crisis alternative case study: Soteria Alaska
The project's aims, what happened, what worked, and what didn't
In these case studies I attempt to learn from previous attempts to change the psychiatric crisis system. These learnings come from publicly available information on the project, internal documents I have access to, and interviews with key project members.
Soteria Alaska was a novel live-in place to care for people having a first psychotic break. It was modelled on Soteria San Jose, a pioneering project funded by the NIMH in the 1970s and 1980s. The high-level principles of the original Soteria project were:
Being with residents as witnesses and participants in their experience, rather than ‘doing to’ or treating them as objects of psychiatric treatment
Little to no antipsychotic medication. This was a research program where newly diagnosed residents were not offered medication for at least 6 weeks other than to facilitate sleep when necessary.
A small, community-oriented, homelike environment, with no more than 12 total residents, including staff
Staff without any particular clinical training, who aimed to be equals with the residents
Long-term stays, up to six months
Open community, with residents encouraged to return afterwards
The idea and initial motivation for the project came from Jim Gottstein, a lawyer and psychiatric survivor who was inspired by Bob Whittaker’s book Mad in America and its vision of an alternative to the use of force and antipsychotic medication in the treatment of psychosis. The book described the Soteria San Jose project as an example of a crisis response project based on a more humane paradigm. Jim decided to start Soteria Alaska because he saw opening such alternatives as a necessary component of the process of wider systemic change, alongside lawsuits and advocacy. He saw this as one side of what he calls the transformation triangle (in his theory of change for the psychiatric system): public education, development of alternatives and strategic litigation.
The Alaska Soteria house opened in 2009 and closed in 2015. It was intended to serve 5-6 residents at any given time. Unlike the original Soteria project, it received mostly residents who had already been prescribed antipsychotic medication. Some incoming residents did not take the medication they had been prescribed or did not take it consistently, but others came with a history of taking medication, so helping residents taper off medication in a safe way was a part of the Soteria Alaska process in a way it had not been in the original Soteria.
It was funded with startup funding from the State of Alaska’s Mental Health Trust Authority, and a $375,000 annual grant that was included as a line item in the state’s legislative budget. This made up close to two-thirds of the project’s annual budget needs, and an eclectic mix of state safety net funding for room and board and Medicaid funding sources made up the other half.
The Soteria Alaska leaders had mentorship from the leaders of the original Soteria project. In particular, the principal project director of Soteria San Jose, Alma Menn, was very involved as a mentor to Susan Musante, the executive director of Soteria Alaska. They also used the book Soteria: Through Madness to Deliverance, as a guide.
What were some things that worked?
Soteria Alaska had an extremely driven and motivated executive director in Susan Musante. It’s clear that it was extremely challenging to find the necessary funding to keep the doors open every year, and she was able to do it consistently, while protecting the values that the project started with.
Soteria Alaska also initially had advocates and supporters within the Alaska Mental Health Trust Authority, an independent state trust fund established to support Alaskans with mental illness and other disabilities and social and justice challenges.. This made getting and renewing funding possible.
Soteria Alaska’s ongoing state grant was very stable, and was not at risk of being withdrawn based on changing conditions in the project (although it was not sufficient to support the entire program). Reporting requirements were standard and straightforward for all state grants–they had to report the number of people served and progress on the outcomes that were proposed in the initial grant application. This grant was still available for Soteria when the organization closed the project down, but it did not continue to use it and the state did not re-issue the grant to continue the project under the direction of a different organization This is in contrast to other common sources of project funding which have limited durations, extremely onerous reporting requirements, or are only committed to funding the project in a particular phase of its life.
Although there was a lot of turnover amongst staff (unsurprising because most house staff were fairly young) the organization continued to be able to recruit often, with recommendations of current or prior staff.
What led to its closing?
The executive director, Susan Musante, left her position to work elsewhere about a year or two before it closed. The board of directors conducted a search to find a new executive director and hired an interim ED in the meantime. They eventually found a new ED who seemingly held values that were aligned with the values of the project (autonomy, low use of medication, being-with not doing-to). This new director was not able to secure enough funding to fund the remainder of the project’s annual needs and recommended to the board that the program be shut down.
A few years before it closed there was a murder at Soteria Alaska, when a former resident returned and killed another former resident while she was at the house to apply to become a staff member. Multiple sources at Soteria Alaska said this didn’t lead to the project falling apart directly, but may have compounded an already existing sense of burnout or fatigue, particularly at the executive level.
There are multiple possible contributing factors to the project’s closure:
The funding situation being as difficult as it was, the new executive director was unable to secure enough funding to keep it open. Susan had been extremely driven in securing idiosyncratic sources of funding and someone less passionate about soterias specifically would not be able to succeed the way she was.
The Mental Health Trust’s startup funding had waned, and they had asked that the project transition to being funded by Medicaid. Soteria Alaska was not a good fit for the structure of Medicaid funding. The staff hated doing the paperwork for Medicaid and weren’t very good at it, and a lot of their claims got rejected.
The new executive director was more of a mainstream mental health leader than the board had believed her to be, and she prioritized other projects within the broader social services agency that would be easier to fund within a mainstream mental health paradigm. Soteria Alaska was a low priority for her.
There was a general sense of fatigue, particularly around finding funding, that contributed to a drop in motivation for finding funding amongst the members of the board and broader organization.
There was a new state governor whose health department policymakers were less supportive of the Soteria than the previous administration.
It was hard to find good, mission-aligned executive directors who either lived in Alaska or could be convinced to move to Alaska, even with a reasonable pay rate.
What were some challenges it encountered?
The original project team wrote a business plan that involved collaborating with Alaskan native tribes to provide accommodation for indigenous residents in exchange for part of the project’s funding, but this never materialized.
The small size meant they could not do a conventional controlled research study on the outcomes of residents at the soteria. What was done instead initially was a fidelity study, to see how well the treatment matched the treatment at the original soteria (which was studied intensely). Later a program evaluation of clinical and functional outcomes was conducted but numbers of participants were small and there was no control group.
The tight budget meant the executive director had to be incredibly resourceful, sometimes filling shifts in the house when there were gaps, and doing a lot of the ad-hoc work that was required to keep the house running. The EDs who arrived after Susan weren’t willing to do this.
Almost all incoming residents were already on some kind of psychiatric medication, so the resident psychiatrist had to prioritize helping residents taper off medication, rather than simply supporting them as needed with medications other than antipsychotics, such as sleeping aids (as was the case in Soteria San Jose).
In the original soteria, staff stayed at the house for 48 hours at a time, in order to create a more homelike environment. This was difficult to organize at Soteria Alaska because staff resisted it, and the executive team tried a lot of different scheduling configurations.
The project founder, Jim Gottstein, had to leave the board early on as he was busy suing the State of Alaska to protect the rights of psychiatric patients, and considered it a conflict of interest to be on the board of an organization trying to get funding from the state at the same time. This may have contributed to the fact that there were a few new and inexperienced board members by the time Susan Musante, the executive director, left and needed to be replaced.
The project did not adapt well to needing to shift its funding source to Medicaid. The temperament of people hired to be with someone in the depths of psychosis did not align well with filling out detail-oriented paperwork. The sister agency, CHOICES, was later able to find employees comfortable with both kinds of work, although it had and still has different priorities.
What were some limitations?
The soteria model as implemented here is pretty expensive to run, because residents live at the house for such a long time (generally six months, in comparison to inpatient stays or peer respite stays, which are often two weeks) and there’s a pretty strong group-size limit to how many people can live in such a place (generally no more than 12, with a ratio of 1:3 staff to residents).
Getting proof that the model works, or even understanding how well it works, is pretty difficult. The Soteria model works on an assumption that giving someone intensive help when they first have a psychotic break, and helping them reduce or avoid antipsychotic medication entirely, leads to better lives, and lower healthcare costs overall. However, you would need to follow ex-residents for many years afterwards to find out if this were true, and this project (like many similar ones) didn’t have the budget for that scale of research project, nor was the size of the cohort big enough to be confident about the measured impacts even if you did research it.
As is the case for any non-medication strategy for treating psychosis, it’s extremely difficult to find patients who have never been given antipsychotics nowadays, as they are considered the ‘gold standard’ treatment (particularly in emergency environments). So doing any sort of RCT or trial that involves a significant population of medication-naive patients experiencing psychosis would be extremely difficult.
The initial project funding strategy (money from the Alaska Mental Health Trust Authority) is idiosyncratic to Alaska, and wouldn’t work in other places. Other states may have sources of funding like this but project founders would need to investigate to find them, and they may have stricter funding requirements.
Such a small project is pretty vulnerable to shocks (an individual tragic incident, the loss of an executive director). Such problems happen in bigger organizations (murder does happen in inpatient psych wards too, and executive directors leave organizations everywhere) but a more established project would be able to adapt to these challenges more easily.
What might other projects learn?
Funding funding funding. It seems like getting and keeping enough reliable, long-term funding to keep the lights on was the biggest determinant of whether the project lived or died. This will not be a surprise to most project leaders, but still good to keep in mind.
Pay attention to commitment to the vision amongst leaders: Funding success seemed closely intertwined with how driven and resourceful the leadership team were (executive director and board) to carry out the vision of the project. Depending on who you talked to, the funding disappeared because the leaderships’ commitment to the vision was lost, or the leadership’s commitment to the vision got slowly burned out because of the challenges inherent in constantly scrambling for funding year after year. I suspect these two worked in a feedback loop, and neither would have been sufficient without the other.
Pay specific attention to funding transitions and leadership transitions: It was suggested that the funding challenges arose when weaning off the startup funding from the Alaska Mental Health Trust Authority several years into the project, because the source of long-term funding had not been established at the beginning, when it might have been easier to get project support. Similarly, the leadership transition was led by the board several years into the project when some key board members had left, and some board members were still new to the project. Recruiting a new executive director and finding a new source of long-term funding are key, existential challenges for a small organization, and probably best done with a lot of advance preparation, in a time when team members aren’t burned out or rotating.
Have a plan for Medicaid: At some point many small programs will need to explore getting Medicaid funding, and doing it successfully without warping the key activities of the organization seems very challenging.
Consider how to build the evidence base for your treatment, and separately how to track the program’s success and challenges for your own needs: It’s likely that it will be easier to get more humane treatment models adopted if they come with the legitimacy of scientific research backing them. At the same time, a given kind of treatment can be very effective or not, depending on the organizational and cultural context. Most peer respite and soteria projects do little to no research and evaluation on themselves. There’s a temptation to use research purely to advocate for the treatment model, not also to improve the program. Figuring out how to have high internal standards, in order to keep improving how well the program helps people, while at the same time building some sort of evidence to use to persuade bigger funders, is a challenge–it’s important, and I also don’t have an obvious piece of advice about how address these competing needs yet.
If you have a suggestion for a project you know of that you think I should study (either an alternative kind of crisis response or an attempt to reform existing crisis response systems) then add it in the comments below, or email me at firstname.lastname@example.org.