|Year : 2021 | Volume
| Issue : 2 | Page : 208-214
The Process of Evolving a National Plan in Suicide Prevention in a Context of Political Violence
Samah Jabr1, Maria Helbich2
1 Head of the Mental Health Unit within the Palestinian Ministry of Health; Psychiatrist, Ibn Rushd, Shu’fat, East Jerusalem
2 Clinical Psychotherapist, Gender and Mental Health Consultant, Vienna, Austria
|Date of Submission||13-Dec-2020|
|Date of Decision||27-May-2021|
|Date of Acceptance||03-Aug-2021|
|Date of Web Publication||09-Sep-2021|
MD Samah Jabr
Head of the Mental Health Unit within the Palestinian Ministry of Health; Psychiatrist, P.O. Box 25195, Shu’fat
Source of Support: None, Conflict of Interest: None
This article reports on suicide and suicidal behaviour in Palestine and sets this in the context of political violence related to the Israeli occupation. Accurate data about suicide and attempted suicide are limited and as such a range of studies including those concerned with the wider Middle East and North Africa region are used here to describe the context for suicide. The article indicates some of the individual and societal risk factors associated with suicide in Palestine and reflects on the role of Islam and religious leaders in tackling the stigma associated with suicide. It describes current mental health services for those who may attempt to take their own life and then outlines the steps that the Ministry of Health is taking to develop a national plan in suicide prevention.
Keywords: mental health, Palestine, political violence, suicide, suicide prevention
|How to cite this article:|
Jabr S, Helbich M. The Process of Evolving a National Plan in Suicide Prevention in a Context of Political Violence. Intervention 2021;19:208-14
Key implications for practice
- The capacity of health services and MHPSS needs to be improved to enhance suicide prevention services in Palestine.
- MHPSS practitioners should strengthen the message that suicide is not a crime but a multidimensional mental health problem.
- To reduce stigma around suicide, it is important to target gatekeepers, including religious leaders.
| Suicide in Palestine|| |
Data about suicide and attempted suicide in Palestine are rare and studies are limited. This is reflected across Arab countries in general, with the suggestion that the role of religion and the associated stigma of suicide make it likely that reporting does not accurately represent the incidence of suicide. Eskin et al. (2019) point out that while all religions prohibit suicide, Islam has the most prohibitive attitude towards suicide, expressed through a word of God in the 4th surah of verse 29 in the Qu’ran: “And do not kill yourselves [or one another]. Indeed, Allah is to you ever Merciful.” While there are different translations and interpretations available, this religious position demonstrates a prohibitive stance towards suicide that also reminds believers of the mercy of God. In their study with university students in 12 Muslim-majority countries, Eskin et al. (2019) concluded that suicidal thoughts and attempts were however quite frequent among young adults, despite the religious scripture specifically prohibiting suicide. They showed that significantly more students from Palestine (23.6 %), along with Saudi Arabia (38.7%), Azerbaijan (31.1%) and Indonesia (31.7%), had attempted to take their lives by suicide in comparison with other Muslim-majority countries. They link this finding about Palestinian students with the high number of mental health disorders in Palestine.
Itani et al. (2017) in a global school-based student health survey in the Gaza Strip and West Bank explored suicidal ideation among students aged 13–15 years. The study found that the overall prevalence of suicidal ideation and/or planning was 25.6% and that males were more likely than females to report suicidal thinking. The prevalence of suicidal thinking was higher than the rates of other participating countries in the Eastern Mediterranean region such as Iraq (22.0%), Jordan (23.7%), Kuwait (22.7%), Lebanon (18.5%), Morocco (22.6%), Tunisia (23.2%) and the United Arab Emirates (15.6%), underlining the need for improved access to mental health services.
There is data available from the Palestinian Police Research and Planning Department for the number of suicides in Palestine for 2018 (Khatib, 2019). There was a total of 35 people who took their lives by suicide − 23 in the West Bank and 12 in Gaza. In the West Bank, 218 people attempted suicide; of these, 157 were females and 61 males. It is however assumed that these numbers are not accurate, as the majority of suicide cases are not reported. According to Palestinian law, attempting suicide is considered as committing a crime. In the West Bank, people who assist those attempting to take their lives may also be subject to legal proceedings. In practice most people do not go to prison if they attempt suicide. However, they are interrogated by police, threatened to be imprisoned and their families are often contacted and intimidated.
In countries where suicide remains a taboo and the social and personal stigma around it is very high, and where attempting suicide is considered illegal (Eskin et al., 2020), there is likely to be increased reports of incidents of certain forms of unnatural deaths, such as car accidents or drug overdoses, pointing to a lack of reliable records of suicide. In the clinical practice of one of the authors, for example, people articulate their wish to take their lives by disguising their suicide attempt as an accident so as not to bring shame on their families. These incidents will not be registered as suicide cases, which explains the discrepancy between the official numbers and clinical experiences on the ground. Karam et al. (2006) in a study on suicidality in the Arab world support this argument by pointing out that families and patients prefer not to have their attempted suicide reported as a means to avoid legal sanctions and stigmatisation.
Another contributing factor to the lack of accurate reporting in this area is that public hospitals take the lead in collecting data of attempted suicides in Palestine. However, most people who have attempted suicide do not typically go to a public hospital for treatment. They are either not treated at all, treated at home or access private hospitals. This highlights the need for reliable documentation of attempted suicide cases across the whole health system.
A final consideration is a longstanding avoidance amongst practitioners to initiate dialogue with those affected by suicide in Palestine. This is related to underlying fears that talking about suicide would result in others copying behaviours leading to suicide or cause people to consider suicide. Unfortunately, this counters an important prevention measure for suicide which is to openly talk about suicidal ideation and to give people who are contemplating suicide an opportunity to express their feelings (National Institute of Mental Health; APA, 2018).
| Risk Factors for Suicide|| |
In order to understand the prevalence of suicide, suicide attempts and suicidal ideation, and as a means to develop prevention measures, attention must be given to the underlying risk factors. A study conducted by Médecins du Monde Switzerland (MdM CH) in 2019 on suicide in Palestine classifies risk factors into five categories: individual, familial, economic, institutional and social factors. Suicide attempts are multicausal, indicating that each of these factors can contribute to the emergence of suicide risk. At the individual level, mental illness, poverty and unemployment, feeling of worthlessness, academic failure, drug addiction, loss of close family members and lack of coping mechanisms were identified as the main causes. Marital and family conflicts, romantic breakups, negligence and poor relationships with family members can be regarded as familial factors. At the societal level, feelings of isolation, discrimination, gender-based violence (GBV) as well as lack of social support on the institutional level are main issues. In general, having already attempted suicide is a huge risk factor, in line with data from around the world (Khatib, 2019).
Individual Risk Factors
There are a few studies that detail individual risk factors for various population groups in Palestine. Itani et al. (2017), for example, examined suicidal ideation risk factors in students between 13 and 15 years of age living in the West Bank and Gaza. They were found to be marijuana use, having no close friends, tobacco use, loneliness, worry-induced insomnia, food insecurity and being the victim of a bully. Massad et al. (2016) highlighted the consumption of alcohol and illegal drugs in their cross-sectional qualitative study on risk taking behaviours in Palestinian youth in the West Bank. With alcohol and drugs being easily available, the research found that they were used for a range of reasons, including stress, inadequate parental control, lack of awareness, unhappiness, curiosity and to cope with the effects of the Israeli occupation. Indeed, the study by the National Institute of Public Health in Ramallah, in collaboration with UNODC, the Ministry of Health (MoH) and the World Health Organization (Palestinian National Institute of Public Health, 2017) on illegal drug use in the West Bank and Gaza indicated that 1.8% of the male population above the age of 15 could be classified as high-risk drug users, associated with the socioeconomic context, characterised by political and economic tensions in Palestine.
Societal Risk Factors
The social suffering of Palestinians caused by the social and political context and the oppressive system of the Israeli occupation is often disregarded or downplayed with regard to suicide in Palestine, such as when researchers or journalists are looking for answers solely by focusing on individual traits. Suicide is almost never solely explained by individual experiences but has a strong structural and societal component − even more so, when people are disproportionately affected by structural violence, including inequities, discrimination, oppression and historical trauma.
Eskin et al. (2016) attribute the prevalence of suicide attempts among Palestinian students to the psychological impact of living under occupation, in particular to the restrictions on movement, lack of peace prospects and economic and social hardships. Cultural and social factors contribute to the causation of mental health illnesses (WHO, 2008). Continuous exposure to a violent context such as the high prevalence of traumatic events in Palestine combined with political instability and lack of security will negatively affect the mental health and psychosocial wellbeing of a society. Dabbagh’s study of suicides in Palestine (2005) confirms this by stating that the causes of taking one’s own life are to be found in cultural, social, economic and psychological factors that are exacerbated by the human rights violations and the political system of the Israeli oppression.
One of the most obvious symbols of the Israeli oppression is the fragmentation of the occupied territories. The separation wall and the web of checkpoints and road barriers restrict movement in Palestine and lead to the displacement of people and families and dispossession of homes. Consequently, communities and families are cut off from each other and from services they need. All these measures and symbols of oppression affect the psychosocial wellbeing of Palestinians by destroying a sense of home, safety, community cohesion and cultural identity and by being a source of distress, constant humiliation and harassment (Batniji et al., 2009).
The exposure to violence and discrimination is particularly damaging to children and youth. The imprisonment of children and young people is widespread and impairs their wellbeing gravely (B’Tselem, 2020; UN General Assembly, 2018). The most common offence is the throwing of stones, which is punishable by up to 20 years imprisonment under Israeli military law (Addameer, 2017). A UNICEF study concludes that the abuse of Palestinian children who come into contact with the Israeli military detention system appears to be widespread, systematic and institutionalised (UNICEF, 2013).
The recent escalation of violence in May 2021 has resulted in the death of 242 Palestinians, including 66 children, 38 women and 138 men in Gaza. Around 1948 Palestinians have been injured, including 610 children, 398 women and 940 men. Essential infrastructure was heavily damaged, including education facilities, hospitals and healthcare centres. A severe mental health impact on children and families is already reported by local organisations, particularly on children who are showing serious physical and psychological symptoms following intense Israeli shelling. Without a rapid intervention, it is estimated that many may develop severe mental health suffering (OCHA, 2021).
Despite this, there is little effort by the international community to acknowledge human rights violation and to address these injustices on an international policy level. Legal, social and moral justice have a reparative function not only for the individual but also for society. Consequently, when solidarity and calls for justice are more often silenced by the powerful party, when Israel is not held accountable for its violation of international laws (UN General Assembly, 2014; International Court of Justice, 2004) and when victims of violations are often framed as terrorists, the lack of international solidarity and efforts of redemption will affect the mental health and psychosocial wellbeing of Palestinians.
The current coronavirus disease 2019 (COVID-19) pandemic is also expected to have long-lasting effects on mental health and wellbeing, including suicide. Although there are presently few large-scale observational studies regarding the effects of COVID-19 on mental health, outbreaks of infectious disease are generally associated with psychological distress. Previous epidemics have shown that the number of people affected by mental health issues tends to be larger than those directly affected by the disease (Ornell et al., 2020). Social isolation and feelings of loneliness may increase the risk of suicide (Sani et al., 2020). While quarantine and self-isolation are necessary measures to stop the escalation of the disease, attention needs to be paid to the possible long-lasting psychological effects (Brooks et al., 2020) and the impact of the pandemic on suicidal ideation.
| The Role of Islam|| |
For most Palestinians, religion is an important part of their lives. The apparent prohibition of suicide by Islam may thus be regarded effectively as social policy for public health. There are a number of Hadith (transmitted reports of the sayings, doings or approvals of prophet Muhammad) that are interpreted in a way that criminalises suicide attempts. For example, certain interpretations claim that whoever purposely kills himself will dwell in hellfire forever or cannot be buried in a Muslim cemetery. Patients will often express fatigue with their lives and a desire for death, but refrain from suicide because of the religious prohibition against it. When someone does take their life by suicide, the whole family of the deceased is stigmatised too. This has grave consequences for their wellbeing and silences openly talking about suicide.
However, many communities in Palestine trust religious leaders and seek their assistance when confronted with suffering. As such, religious counselling could play an essential role in preventing suicides, removing stigma and providing support for family members traumatised by the sudden and unexpected death of their family members. In addition, Islamic literature contains helpful passages about healing and hope that can strengthen the resilience of people. Religious leaders could therefore comfort families of deceased, encourage prayers and take a stand against stigmatisation (Jabr, 2019). Collaborating with religious leaders was therefore early on identified as a key factor in suicide prevention in Palestine, as will be discussed later in more depth.
| Current Mental Health Service Responding to Suicide|| |
Médecins du Monde Switzerland assessed the care in four hospitals in the Southern West Bank provided to people who had attempted suicide (Khatib, 2019). They found that when a person who has attempted suicide is admitted to hospital, it is emergency room (ER) doctors who assess whether that individual needs to stay in the hospital, be referred to the Community Mental Health Centre (CMHC) for follow-up treatment or to a psychiatric hospital. Patients’ perceptions of the healthcare services provided in the emergency units were generally positive. However, they reported receiving insufficient information regarding a treatment plan, follow-up care, treatment benefits and risks. There were also complaints about the judgemental and negative attitudes of some health staff. A follow-up appointment with a psychiatrist was organised for only half of the patients (50.4%) participating in the study. The healthcare providers in the emergency units were found to lack expertise and skills regarding case evaluation, treatment and the referral of individuals who had attempted suicide and they indicated their need for more specialised training.
The lack of specialised public and private hospitals in Palestine in general means that there is no proper care and access to health services for those who have attempted suicide. There are also no specialised hotlines in Palestine as part of suicide prevention services. Furthermore, despite having National Mental Health Referral Guidelines, healthcare providers are unclear as to where to refer patients, Due to concerns about confidentiality or feelings of shame and stigma, many patients prefer to use private hospitals or to be treated at home. Even where patients are admitted to hospital, they typically are not likely to wish see a psychiatrist or mental health professional after discharge or lack the financial means to continue with their follow-up treatment (Khatib, 2019). This is despite the fact that the MoH provides for free psychological treatment after discharge. This reluctance on the part of patients needs to be examined in further detail, linked to how social stigma can be reduced and help-seeking behaviour promoted.
Suicide Prevention Measures in Palestine
The National Committee of Suicide Prevention was established in 2017 in Palestine to ensure unified and coordinated efforts in the prevention of suicide. It is composed of representatives from the MoH, the Ministry of Education (MoE) and Higher Education, the Ministry of Awqaf (Ministry of Religious Affairs), the Public Prosecution Office, the Family Protection Unit of the Police, United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), the WHO and international and national NGOs.
Spearheaded by the Mental Health Unit of the MoH, a number of suicide prevention actions have been implemented in the past few years by the MoH and national and international NGOs, such as the upgrade of quality of care, development of referral mechanisms and active follow-up mechanisms. One directive has been to facilitate referrals of cases of attempted suicides from general hospitals to public CMHCs for follow-up and treatment, exempt of fees. Other initiatives have included the capacity building of healthcare professionals, more specifically nurses and doctors, on suicide intervention and the training of health staff working in governmental primary health centres on the WHO Mental Health Gap Action Programme. While these interventions were starting to show results, for instance, through an increase in referrals for follow-up treatment, a comprehensive multisectoral suicide prevention strategy was critically needed.
National Suicide Prevention Strategy 2021–2026
In response, a National Suicide Prevention Strategy for 2021–2026 was developed, signalling the commitment of key stakeholders from the public and private health and mental health sector, as well as those from education, social development, justice, law, religious affairs and the media. The national strategy was developed with the goal to be culturally sensitive and relevant to the political context in Palestine. Civil society institutions and mental health professionals with vast experience in offering MHPSS services in the Palestine were involved in writing the strategy, as well as different local and international NGOs who were invited to participate by reviewing the first draft and providing feedback. The strategy draws on methodologies and activities that are evidence based and appropriate for the cultural context, including the crucial involvement of religious leaders.
While the national strategy will be applied both in the West Bank and in Gaza and no different measures were proposed for the two different territories, feedback from mental health professionals in Gaza was taken into consideration and included in the strategy. In addition, the action plan, which will be developed following the strategy, will consist of specific action points for the two territories to take divergent needs into consideration.
The National Strategy has five strategic objectives which are presented in more detail below.
Objective As suicide remains under- and misreported in Palestine, the first objective focuses on monitoring suicide rates more effectively way to better identify at-risk individuals and trends in suicidal behaviour, such as quarterly reports to be sent to the Mental Health Unit of the MoH. Close collaboration with the Child Protection Network is recommended to identify at-risk children and youth and to follow up on psychological treatment. The objective further aims at improving case registration in hospitals by drawing particular focus on non fatal self-harm and on the accuracy of death registrations at hospitals.
Objective 2: Reduce the stigma and taboo related to suicidal behaviour and increase public awareness of suicide, attempted suicide and self-harm
The taboo and stigma associated with suicide in Palestine is a major obstacle for patients and healthcare professionals alike. The national strategy is therefore working with families, communities, schools, the Family Protection Unit of the police, health service providers, religious leaders, media and community-based organisations to promote public awareness and spread the message that suicide is preventable. There is still a common assumption among healthcare professionals that it is better not to talk about suicide, so as not to encourage individuals to consider suicide or take action. Matters will not improve if suicidal ideation or behaviour are ignored or silenced.
A key element of suicide prevention is ensuring early detection, especially on the level of primary healthcare. Training public and private healthcare professionals, such as doctors, nurses and gatekeepers (those in a position to identify whether someone may be contemplating suicide, for instance religious leaders, school counsellors, youth leaders, etc.) in the detection of signs of suicidal ideation and risk factors as well as addressing potential stigma in healthcare and educational facilities around suicide is a key factor in enhancing the capacity of services.
It is paramount that individuals with suicide risk have timely access to evidence-based treatments, including cognitive-behavioural therapy, dialectical behaviour therapy or mentalisation-based therapy and continuity of care from detection and response to follow-up. Consistency in care pathways is therefore needed for the assessment and treatment of people vulnerable to suicidal behaviour through the strengthening of referral mechanisms and protocols and clarification of different roles and responsibilities. Current gaps in referrals (between schools, child protection networks, Ministry of Social Development, MoH, Family Protection Unit of the Police) need to be better assessed and addressed to ensure that persons at risk have access to comprehensive Mental Health and Psychosocial Support (MHPSS) services.Objective 5: Restrict access to highly lethal methods of suicide and attempted suicide
While the use of highly lethal methods is not very common in Palestine, it is nevertheless important to be aware of how access to these means might affect suicidal behaviour. Controlling access to means of suicide, such as pesticides, poison or frequently used drugs, has been shown to be effective in reducing rates of death in suicide (Sarchiapone et al., 2011), in conjunction with other suicide prevention strategies. It is therefore advised to monitor their use by engaging regulatory bodies and relevant government sectors.
The different objectives aim at targeting the general population as well as groups with higher risks and vulnerabilities. These were identified as people with a mental health disorder, (ex)-prisoners and (ex)-detainees, people suffering from substance abuse, survivors of GBV, adolescents at risk and LGBTQIA (lesbian, gay, bisexual, transgender queer, intersex, asexual). There is however ongoing debate between mental health professionals and policy makers on whether these issues should be included in the national strategy.
Working Together with Crucial Actors
In order to successfully implement suicide prevention measures, a collaborative effort is needed, both from the governmental side as well as from a wide range of actors in different settings. The following actors were identified in the National Strategy.
Staff Working in Health Facilities
A key element of suicide prevention is improving the quality of care in the public and private healthcare system for individuals with suicide risk. It is crucial that healthcare providers are trained on the detection of suicide ideation and on suicide prevention. This is a process which was already started by the Mental Health Unit of the MoH and will be continued. Additionally, ER staff need to have more knowledge on identifying suicide attempts, self-harm and risky behaviours. Adequate training in risk assessment, intervention, monitoring and follow-up, as well as a clear referral pathway, need to be ensured.
Police can contribute to suicide prevention in different ways. They are often a first-line resource for people who have significant mental health, emotional or substance abuse problems and are among the first to respond to people who may be at risk of suicide. They also play a role in removing access to means for suicide and in assessing the suicide potential in situations involving domestic disputes (WHO, 2009). In Palestine, according to the law, police are informed by hospitals as soon as a patient who has attempted suicide is admitted to the ER, highlighting their important role in responding in a professional way to suicide.
Families are a key resource in engaging in suicide prevention and assisting in recovery efforts of family members who have attempted suicide. As suicide is still a sensitive topic in the Palestinian community, it would be beneficial to offer awareness-raising sessions on suicide prevention within the broader issue of mental health. Families who are caring for members that have attempted suicide should be advised on how to give adequate support and how to talk about suicide, for instance, through home visits by specialised staff.
School counsellors are important gatekeepers at schools, as they are in contact with at-risk students. It is estimated that around 1100 counsellors work in government schools in Palestine. UNRWA also employs school counsellors to provide psychosocial support to refugee students. Educational counsellors generally serve several schools at once and only some are experienced in psychosocial support (MoH, State of Palestine, 2020), highlighting the need for additional training. Teachers also have the responsibility to identify and refer at-risk students to intervention services through the Child Protection Network under the Ministry of Social Development (MoSD), making it necessary for them to be able to assess risk behaviour in students. Another key group in suicide prevention is the students themselves. Peer-to-peer training is an important intervention to strengthen help-seeking norms and to recognise warning signs in their peers in relation to depression and suicide.
Efforts have been made to educate media on responsible reporting of attempted or completed suicide cases by respecting the privacy of bereaved families, not sensationalising suicide and providing accurate information on where and how to seek help (WHO, 2017). These efforts have taken effect and suicide is covered more often by the media in Palestine. This helps to counter previous tendencies to silence the topic, whereby policymakers were afraid that talking about suicide would increase attempted suicides or imitation. The media plays an important role in changing misconceptions about suicide and raising awareness, especially when delivered via specific social media channels. If done in a respectful, responsible and educated manner, information disseminated in this way can contribute positively to suicide prevention efforts.
Religious leaders play a crucial role in raising awareness on topics such as mental health and in reducing the silence around suicide. One of the authors (SJ) has been involved in strengthening collaboration with religious leaders in her role as Head of the Mental Health Unit at the MoH for many years. It is of critical importance for mental health professionals and policy makers to engage in an open dialogue with religious leaders on issues around mental health. There is often a misconception in religious circles that mental health professionals are atheists and that mental health problems are the result of weak faith or possession by spirits. Promoting the mental health knowledge of religious leaders and stimulating a dialogue on norms and values will allow them to support individuals who are suffering, to advise families, to encourage solidarity and understanding, and to prevent communities from showing attitudes of judgement and rejection. In order for religious leaders to contribute to the national effort in the prevention of suicide, mental health and counselling training should be included in institutions for religious studies. These trainings were planned for May 2021 but due to the current political situation and escalation of violence, there has been a delay in implementation. The aim is not for religious leaders to become mental health professionals, but enlightened leaders who show understanding for the suffering of individuals. Encouragingly, there has already been a noticeable change in sheikhs referring people suffering from mental health issues to professionals for support, as attested for by the mental health professionals working in Palestine.
The National Strategy for Suicide Prevention for Gaza and the West Bank will be published by the end of the year 2021. It has received attention at the Prime Minister level, highlighting an increasing commitment towards suicide prevention. A Suicide Prevention National Committee will be established to implement the planned interventions (setting outcomes, targets, indicators, timelines, milestones, etc.) and will be responsible for monitoring and evaluation responsibilities and for budget allocations.. Civil society institutions will be members of the committee and will also benefit from the national strategy and the corresponding guidelines and trainings offered to them.
| Conclusion|| |
Evolving and implementing a national strategy necessitates real political commitment. While this has been shown on the Prime Minister level, it is important to continue to implement the strategy and advocate for real change. Political bureaucracy has delayed the implementation of the strategy, as well as a shift in priorities due to COVID-19. We believe that the national strategy is an important step in the right direction that needs to be backed up further by studies and research on suicide in Palestine and a continuing dialogue between different actors. Time will tell if there is a real political will to support a comprehensive national response to suicide prevention in Palestine.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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