It seems that the best way to prevent suicide is to speak to the troubled person calmly about the value of life, with empathy, repeating their expressed feelings and without making judgments or getting into a confrontation. As the classic Greek philosopher Socrates said: “I cannot teach anybody anything. I can only make them think.”
This was one of the pieces of advice given at a two-day conference earlier this month called Boharim Bahaim (Choosing Life) for 2,000 educational advisers held at the Jerusalem International Convention Center.
The Education Ministry’s pedagogical administration and the Health Ministry’s unit for preventing suicide joined together to sponsor the conference. Although Israel’s suicide rate is among the lowest in the advanced countries (Belarus and Lithuania are, by far, at the top of the list), between 400 and 500 Israelis end their lives by their own hand in a typical year. Globally, every year, a million people commit suicide.
The phenomenon is a great loss of life and potential, and suicide is a social problem that breaks up families and has a critical influence on thousands of people, said Health Ministry unit head Shoshi Hertz, who runs the national program to prevent suicidal behavior.
“Every suicide or attempt leaves behind scorched earth in the immediate and even distant surroundings of that person. It influences the lives and welfare of thousands of people over many years.” It was the ministries’ third conference for educational counselors on the subject.
Suicide attempts and suicide in Israel involve mostly young people from their teens to early 20s; elderly and chronically ill; immigrants (primarily from Ethiopia and the former Soviet Union); divorced fathers; homosexuals, lesbians, bisexuals and transsexuals; victims of sexual attacks; and people suffering from psychiatric illnesses including depression.
The participants in the conference – mostly young women – have master’s degrees in counseling and work mostly in schools. As they do not spend most of their time looking for possible suicidal behavior among pupils – but rather in dealing with various educational problems – the intensive lectures on suicidal behavior were very helpful.
YAEL, AN educational adviser in a school in the south, told The Jerusalem Post that the conference raised her awareness of emotional problems that could lead teens to attempt suicide. But she said there is a serious shortage of psychiatrists – especially those specializing in youth – to which to refer pupils suffering from depression and other mental problems.
Yet “gatekeepers” such as herself, youth movement counselors and even national service volunteers who recently were selected for identifying young people at risk of suicide can be of much help referring them for psychiatric treatment. They have been installed in formal and informal educational settings. A “gatekeeper” is a kind of “emotional resuscitator” for people showing signs of depression or suicidal behavior. They are trained to ask questions directly but gently on whether the person in distress has suicidal plans. They will try to persuade them to seek help and refer the youth to the proper address to get help.
“Anyone can be a gatekeeper if aware of the signs. You have to keep your eyes open and have personal conversations. Many pupils feel close to their teachers; they know they care, but some don’t feel comfortable speaking to them about their personal problems,” said Yael. “One of my jobs is to pay attention to kids who don’t talk a lot, who are often absent from school. But it doesn’t mean that if they have family problems that they automatically are at risk of suicide.”
She noted that “shaming” of youngsters on social media is a growing risk, even though pupils are being taught now about the dangers of the Internet.
Asked why most of the educational advisers seemed to be relatively young, Anat said there were some before, but the profession “has developed in the last 20 years. We are counselors, not psychologists, but we know how to deal with personal distress. You know when you succeed in making a difference, but you don’t really know when you don’t succeed.”
The signs of possible suicidal behavior are actually using words of desperation (“I want to die,” “I’m sick and tired of living” or “I’ll kill myself”) or showing warning signs without verbally expressing their desire to end their lives. Among the emotional signs are severe sadness, extreme expressions of anger, social withdrawal, dividing up possessions, physical neglect, drastic changes in behavior or reports of sudden “peace.”
Youngsters who attempted suicide before, who had a family member who ended his or her life, confusion about sexual identify, who lost a family member or friend, a history of suffering sexual abuse, alcohol use, having firearms or other fatal means at home or a police record are at high risk.
But having a supportive family or group of friends; normative functioning; a sense of humor or optimism; ideological, religious or social involvement; and problem solving are pluses that counter suicidal behavior, according to experts.
MANY COUNTRIES around the world have activated suicide-prevention programs that have provided helpful; among them are the US, the UK, Germany, Japan and Finland.
In Israel, after many years of preparation, research was conducted and a pilot program was launched by the government at the end of 2013. The cabinet decided in principle that preventing suicide was a “national priority” and that the effort would be led by the Health Ministry with cooperation from other ministries and local authorities.
A national council for suicide prevention was set up as an interdisciplinary body to advise partners in the effort, and an inter-ministry steering committee was established to coordinate. Among the strategies to reduce suicides were the training of “gatekeepers” around the country; proactive detection of people at risk; support with hotlines in various languages via phones and Internet; educational campaigns in four languages; giving support to families of loved ones who have killed themselves; epidemiological research; and the reduction of access to dangerous medications and firearms and fencing in dangerous structures from which people could jump.
DR. SILVANA Fennig, chairman of the child-and-adolescent psychiatric department at the Schneider Children’s Medical Center in Petah Tikva and Tel Aviv University’s Sackler Medical Faculty told the audience that she works regularly in the hospital’s emergency room.
“We get at least five suicide attempts a week there,” she said sadly. “I am a psychiatrist, a clinician. We have many services for children and youths suffering from emotional problems. Our pediatric and adolescent psychiatry department is open. They can leave, and they have to agree to stay.”
Fennig noted that despite the psychiatric reform launched by the Health Ministry earlier this year that transferred responsibility for care from the ministry to the four public health funds – with the aim of improving treatment, increasing accessibility and reducing stigma.
“There is still a stigma in having psychological and psychiatric problems. The remaining red tape also makes it difficult to refer children and youths at risk for assessment.
It’s easier to send them to a general hospital than a psychiatric hospital. Since those who make attempts hurt themselves, we get so many youngsters who have damaged their bodies. They have to be treated.”
The first stage among those who attempt suicide is isolation or suffering bullying or depression. Then, said Fennig, is “suicidal ideation, then a suicidal plan, and then an attempt. It is a chain, so we have a good opportunity to act to prevent suicide at each stage if we identify them. We have no choice but to ask personal questions when making initial contact.”
Psychotherapy and psychological treatment can be effective up to 80% of the time, like antibiotics and vaccines for physical illnesses, she said. The personal connections built between patient and therapist can help in up to 30% of cases.
“But when I learned psychiatry, I wasn’t taught how to make personal connections with patients, so I had to learn it myself. In about 15% of cases, there is a placebo effect, in which they get something that they think helps them. In addition, cognitive behavioral therapy can be helpful in 15% or less of patients. But that doesn’t mean it’s not worth studying it or using it. Short-term treatment can be effective, but it’s not suited to everybody.”
If the patient lacks motivation to get better, it is very hard to fight it, Fennig added.
“There are many books on motivational interviewing of people who have attempted suicide or are contemplating killing themselves.
One can’t offer help to a suicidal teenager who refuses help. But the good news is that treatment can push the patient from one stage to another. The therapist should always express empathy, flow with the patient’s opposition without confrontation and support his self abilities.”
Fennig screens segments of a US film from the 1960s in which a girl who attempted suicide by drinking vodka along with a whole bottle of aspirin is saved from herself. The therapist she was taken to – a psychiatrist friend of her father – lectures and berates her and states that she will be hospitalized in a mental institution. He also accuses her of causing sorrow to her family. None of this helps.
“We have to put ourselves in their shoes, not just express empathy and compassion,” said Fennig. “We have to understand the positive and liberating feeling of contemplating death by ending their suffering.
Until we are there, we won’t understand their distress. Never judge or moralize. That doesn’t mean we are in favor of death, but we have to understand those who feel that it is a haven for them. First listen before you say anything. Use reflective listening by rephrasing what they say.”
If the patient says she has no one who is important to her or to whom she is important, repeat it. She may change her words to say: “Maybe there is one friend who cares.”
Then build on that, suggested Fennig. “The person must choose life. We can help, but it is his or her own decision.”
When a patient who attempted suicide finally gets the message, he or she often says: “But why didn’t you tell me how precious life is?” She responds just as Dorothy as told in The Wizard of Oz when she said “There is no place like home.” If she had been told in the beginning, she wouldn’t have accepted the fact that cyclone-prone Kansas can be considered home, Fennig concluded.
PROF. GARY Diamond, a clinical psychologist and head of the psychology department at Ben-Gurion University of the Negev in Beersheba, focused on how parents can be helped to fight their children’s depression and suicidal tendencies.
“We developed our technique over 20 years. Even in the best of circumstances, there are stressors in adolescence: doing schoolwork, forming your personal identify, making social friendships and romantic relationships, feeling comfortable in your body.
Extra stressors include depression, bipolar disorder, losses due to death in the family or divorce, violence, shouting and lack of safety,” said Diamond.
“There is also victimization, discrimination because one is in an ethnic, religious or sexual minority or shows atypical behaviors.
All of these can raise the risk of suicide.”
But, he said, parents can protect by providing a safe haven. Healthy teens use their parents for support, comfort, protection and direction during times of severe distress.
“Kids who succeed in school, have strong ties with others, but deep inside respect their parents – that they can help at a time of stress and crisis.”
Diamond and colleagues teach parents to respond in an empathic, curious, warm manner so their offspring feel loved, supported, understood and important. They internalize that the parent is somebody who will be there for them and comfort them in times of need. Eventually, they will be able to soothe themselves. It is a buffer against depressive and suicidal symptoms.”
PROF. ALAN Apter, another pediatric psychiatrist at Schneider who is a leading Israeli expert in suicide, noted that killing oneself is the third leading causes of death in Israeli 15-to-19-year-olds, after accidents and homicides.
“Up to a third of teens think at least once about suicide almost every night. I am regularly called to the hospital at night to deal with girls who had attempted suicide. Girls attempt it more, but boys do it more without just attempts. Males tend not to ask for help. Attempts are very predictive of actually committing suicide, but less so in youths and more in older people.”
Among those who attempt suicide, there are three groups, he said. First those who are narcissistic, perfectionists who are unable to tolerate failure; then those who are impulsive, aggressive and oversensitive, especially girls; and those who suffer from hopelessness related to underlying depression (the boys typically develop schizophrenia). This, he said, is very dangerous and explains many sudden suicides.
Acute depression can be treated in 12 weeks, followed by remission, but, said Apter, treatment has to be continued for six months or more with maintenance for at least a year.
Such patients are at risk for their whole lives, but they can nevertheless have good and productive lives. Altogether, “our treatments are not very successful. Cognitive behavioral therapy success is 54% to 60%. Interpersonal (talk) therapy is 60% to 75% effective. Some drugs can be even more effective.”
However, some patients still fall through the cracks. Perhaps, he suggested, in the future, genetic testing may be carried out to see who would react positively to drugs and who would benefit from psychological treatment.
“In the future, even anti-inflammatory agents might improve treatment response for depression.”