Intervention before lives are lost

A government pilot project to prevent suicides – due to go national from 2013 to 2015 shows signs that it is paying off.

Preventing someone from taking his own life does not have to wait until he’s standing on the edge of a roof and looking down. One is much more likely to succeed if those at risk for suicide are identified early on and helped out of their desperation and depression to understand that life is nevertheless worth living.
An inter-ministry committee set up in 2005 developed a pilot program under the leadership of the Health Ministry, now about to enter its fourth year of implementation in three locations around the country, that has already shown some progress in this regard. Between 2013 and 2015, it will gradually expand to the rest of the country.
Official statistics show that some 400 people (residents and tourists, adults and minors) commit suicide in Israel in an average year (although the actual figure is estimated to be 20 percent higher) while annual road deaths average 370, says Yemima Goldberg, director of the National Suicide Prevention Program.
More than 6,000 Israelis reach emergency departments in an average year after attempted suicide, and it is estimated that there are another 2,000 unreported attempts by those who do not go to the hospital for treatment.
Every month, Magen David Adom is alerted to some 600 calls due to attempted or actual suicide. As these incidents are accompanied by much social stigma, it is difficult for the authorities to collect accurate data.
“While the government spends NIS 300 million a year to reduce the human toll on the roads, just NIS 37m. will be spent on the suicide prevention program,” continued the ministry’s chief psychologist.
Goldberg, a clinical psychologist who graduated from Tel Aviv University, is in charge of 500 psychologists working in the public health system and responsible for registering all such professionals. She has been involved with plans to reduce suicide since 2004, a year before becoming chairman of the inter-ministry committee.
Her department is very small, with a deputy director and three-and-a-half job slots for administrative workers.
She is grateful for what she has, but wishes she had a larger staff, such as exist in many countries, such as Scotland, where she made a professional visit. Her department, she notes, is also involved in promoting the treatment of children subjected to sexual abuse, victims of domestic violence and other problems.
A few years before her arrival, the ministry had produced a sophisticated “kit,” complete with detailed booklets and slides, aimed at promoting the reduction of suicide among children and youths. However, Goldberg says the kit was not a training program but only a tool to promote awareness in schools. “I suppose it helped somewhat,” she adds.
Almost seven years ago, Dan Naveh represented Israel at a Helsinki meeting of health ministers from around the world where they signed a commitment to develop and implement suicide prevention programs. Goldberg assembled a number of agencies by the issue in addition to her own ministry. These included the Education Ministry; Welfare and Social Services Ministry; Immigrant Absorption Ministry; Industry, Trade and Employment Ministry; academic institutions; the Jewish Agency and voluntary organizations. Others, including the Israel Defense Forces, joined as time went on. Health Ministry associate direcor-general Dr. Boaz Lev provided much of the impetus towards action in minimizing suicide.
“We decided that there was enough talking; the time for doing something had come,” Goldberg recalled. “We went to the Knesset and appeared before the Knesset Finance Committee, which was then chaired by MK Ya’acov Litzman [who is now deputy health minister]. He understood it was the state’s responsibility and agreed to allocate money for a project to prevent suicides.”
Funding for the multi-year pilot project will total NIS 6m.
“We studied in depth what was being done in the rest of the world and found a number of effective strategies.
The pilot project targeted three populations – the elderly, youth and immigrants [that is, recent arrivals from the former Soviet Union and Ethiopia].”
Thus it focused on Rehovot, Ramle and Kafr Kanna (in the Galilee). Rehovot has numerous immigrants; Ramle is a mixed city with Jews and Arabs and Kafr Kanna is solely Arab.
A quarter of the funds came from the American Joint Distribution Committee, which hired a manager for the pilot program, and the rest from the Health Ministry.
“We built the infrastructure and trained people for their jobs. We had to persuade the schools to let us in, and preparations took a year,” says Goldberg.
The pilot project began in 2009 and was supposed to become a formal program in 2012, Goldberg says, but when it was realized that not enough time had passed for effective evaluation of the program, the steering committee decided to add 2012 and start the national program in 2013, with gradual expansion around the country and an annual cost of NIS 37m.
The program, continues Goldberg, is based on the use of “gatekeepers” – teachers, educational advisers, social workers, dormitory school counsellors, absorption workers, health fund personnel, youth movement leaders and others who are not experts in suicide prevention but who can readily detect signs of distress.
Social networks regularly used by the young are monitored for signs of distress, and gatekeepers are called in if deemed necessary. Goldberg learned that hairdressers and even taxi drivers are used in some countries to serve as a shoulder to cry on and can alert the authorities of customers’ talk about suicide.
Among those specially trained for the project were 600 gatekeepers; 300 psychiatrists, psychologists, social workers and educational advisers; and 500 volunteers in the Jewish (through ERAN, Emotional First Aid) and Arab sector (through the Sahar organization). Some 150 street signs were set up, 1,000 flyers were distributed and 300 posters were hung. Questionnaires also help identify people at risk. As such a multiplicity of factors were involved, many sessions were held to coordinate among them.
Early warning signs that a person may be suicidal include extreme behavior, illogical fears, neglected appearance and changes in the way they talks; depression, the use of drugs and alcohol; risky acts such as running away from home, dangerous games in public and excessive piercing; fighting, lying or vandalism; and a decline in studies, concentration and an increase in absenteeism.
“We invested a lot in informational and educational material in four languages,” says the ministry’s chief psychologist.
Short video messages and other material to reduce stigma were posted on websites. “We even produced a play in Amharic for Ethiopian immigrants, using a director and actors from the community itself. They have so far performed eight times in community and absorption centers, and they really put the message across. The message is very powerful. We may produce a play in Russian as well.”
Not only are people who attempt suicide at high risk of trying again, but also people from families that suffered a loss in their family due to suicide, she continues.
“We try to identify them so they do not reach hospitals without being recognized at being at high risk. The main target groups are not only the young, including soldiers, but also adults of all ages, including the elderly. People who have been divorced or widowed, homosexuals and people with mental problems are also at higher risk.
The National Insurance Institute help us with the elderly, while ERAN answers many anonymous phone calls from distressed people of all ages who threaten suicide,” Goldberg says. “The problem cuts across the entire social fabric, people of all ages, cultures and religions.”
T h e gatekeepers have been trained to identify those at risk, give them short (12-week) treatment including cognitive behavioral therapy (CBT) and the less-familiar dialectical behavior therapy (DBT) and interpersonal psychotherapy (IPT).
CBT is a psychotherapeutic approach based on talk therapy that aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure in the present. As there is evidence that this technique is effective for the treatment of numerous emotional problems such as anxiety, eating, mood and personality disorders, as well as substance abuse, it is a good option for those who have attempted or considering suicide.
DBT is a system of therapy originally developed by University of Washington psychologist Marsha Linehan to treat people with borderline personality disorder. It melds standard CBT with concepts of distress tolerance, acceptance and mindful awareness related to meditation techniques.
Research has shown it can help treat people with suicidal tendencies.
IPT is a time-limited psychotherapy that focuses on interpersonal relationships and building interpersonal skills. It originated with Harry Stack Sullivan, an American psychiatrist and psychoanalyst born at the end of the 19th century who was strongly influenced by sociology and social psychology. It developed in the late 1970s and 1980s as an outpatient treatment for adults who were diagnosed with moderate or severe clinical depression.
New regulations require informing parents that their child has attempted suicide. If they live in the pilot project locations, they can be treated immediately, says Goldberg.
“All the hospital emergency departments in the three towns where the pilot operates have been told what we offer.”
She reports a three-fold increase in the number of people sent for treatment in clinics in areas included in the pilot project.
The JDC, working with an independent observer, has been assessing the pilot project.
“It’s difficult to document a reduction in suicide in the three towns in such a short time, but there are assessments by people who give treatment who believe it has already helped. For example, there were two suicides a year in Kafr Kanna in 2006 through 2009, but in 2010, there were none.
“There has also been a reduction in Rehovot and Ramle, but we need more time and research to learn whether this resulted from the proactive approach of the pilot project,” she says.