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| FIELD REPORT |
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| Year : 2021 | Volume
: 19
| Issue : 2 | Page : 249-254 |
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An Initiative in Suicide Prevention: Best Practices, Challenges and Lessons Learnt from Nepal
Parbati Shrestha1, Sita Maya Thing Lama2, Rambabu Nepal3
1 Project Coordinator, Program Department, Transcultural Psychosocial Organization, Nepal
2 MA Clinical Supervisor, Program Department, Transcultural Psychosocial Organization, Nepal
3 MA Field Coordinator, Program Department, Transcultural Psychosocial Organization, Nepal
| Date of Submission | 06-Apr-2021 |
| Date of Decision | 04-May-2021 |
| Date of Acceptance | 05-Aug-2021 |
| Date of Web Publication | 09-Sep-2021 |
Correspondence Address:
MA Parbati Shrestha
Project Coordinator, Program Department, Transcultural Psychosocial Organization Nepal, Anek marga, Baluwatar, Kathmandu Nepal G.P.O Box 8974/C.P.C. Box 612
Nepal
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/INTV.INTV_11_21
Suicide is a major problem at the current time in Nepal. Although suicide needs a multisectoral and comprehensive response, it is challenging to work in a community where mental health and psychosocial support are not available or are limited. These challenges are related to the lack of mental health services in the community, lack of awareness and help-seeking behaviours, and interpretation of suicide as a consequence of social problems. Drawing on the local experience of working in the community to the national level, we recommend some best practices on behalf of Transcultural Psychosocial Organization Nepal to overcome these challenges and to improve the outcomes in our mental health and psychosocial support response to the suicide prevention programme.
Keywords: community, media campaign, suicide, suicide prevention
How to cite this article:
Shrestha P, Lama SM, Nepal R. An Initiative in Suicide Prevention: Best Practices, Challenges and Lessons Learnt from Nepal. Intervention 2021;19:249-54 |
| Introduction | |  |
Suicide is one of the leading causes of death worldwide with more than 800,000 deaths every year, one in every 40 seconds (WHO, 2014). Although Nepal does not have reliable data on suicide, records by Nepal Police show that death by suicide is rising every year (Hagaman, Maharjan, & Kohrt, 2016; Marahatta, Samuel, Sharma, Dixit, & Shrestha, 2017). Suicide in Nepal is underreported due to fear of criminalising it and fear of being entangled in legal problems if reported (Hagaman et al., 2016; Karki, 2011).
Decade-long conflict in Nepal, the massive Gorkha earthquake in 2015 (Marahatta et al., 2017) and the current pandemic have all contributed to the rise of mental health issues, including suicide (Banerjee, Kosagisharaf, & Sathyanarayana Rao, 2021). The earthquake itself caused huge losses of property and life and impacted people’s mental health (Kane et al., 2018). As an organisation, we have observed an increasing trend in the number of deaths from suicide over the last four years (TPO, 2020). However, unfortunately Nepal lacks a national suicide prevention strategy, the health system does not record suicidal ideation, and health personnel are not trained in screening and supporting people with suicidal ideation. As a result, mental health programmes including suicide prevention are conducted in a fragmented way.
| The Transcultural Psychosocial Organization Initiative in Suicide Prevention | | |
Transcultural Psychosocial Organization (TPO) Nepal is one of the leading organisations working in mental health and psychosocial support in Nepal. During the 2015 earthquake, TPO Nepal provided mental health and psychosocial support in 14 severely affected districts (Hossain et al., 2015). Among them, Sindhupalchowk district had the highest number of human casualties with 3570 fatalities and 1569 serious injuries. A study conducted in three of these districts (which included Sindhupalchowk) showed that one out of three adults had depression-related symptoms and distressing levels of anger; one out of five were engaged in hazardous drinking; and one out of ten had suicidal thoughts after 4 months of the earthquake (Kane et al., 2018). The emergency response included a range of mental health and psychosocial programmes including psychological first aid (WHO, 2011).
Despite the implementation of numerous programmes focused on mental health and psychosocial care, requests from the community and government officials were received for a focused suicide prevention programme. TPO Nepal therefore decided to conduct a series of consultation meetings and group discussions to find out more about the problem. Consultations and discussions were conducted with bereaved families and key persons from the community including community members, teachers and health workers. These discussions helped in prioritising our organisation’s tasks for suicide prevention as follows:- Community-based psychosocial care and support
- Media awareness and advocacy
- Use of flipcharts for psychoeducation
- Information for key stakeholders on suicide and suicide prevention
- Health systems strengthening
Community-based Psychosocial Care and Support
The major component of the programme was psychosocial care and support which included mobilisation of psychosocial counsellors and community-based psychosocial workers (CPSWs). They all had basic listening skills and training in screening for more acute problems. The psychosocial counsellors were trained for at least 6 months in helping skills, including providing counselling services. These counsellors and CPSWs conducted home visits and met with families and individuals who were in grief after losing family members due to suicide and where necessary referred to other services for further support. They aimed to assist families in dealing with loss and grief and in identifying warning signs for suicide and suicidal ideation of family members. Those individuals with suicidal ideation or who had made a suicidal attempt and those families with a history of suicide were referred for counselling sessions. The symptoms commonly observed included difficulty in sleeping, loss of appetite, dizziness, worrying, headaches and being anxious. Individuals with a history of suicide in their families expressed feelings of guilt as they had not been able to notice warning signs of suicide. Counsellors provided counselling support by listening to emotional difficulties, providing a safe place for feelings to be ventilated and validated. They helped individuals to identify constructive and destructive coping, and assisted them in making safety plans. Biweekly and monthly supervisions were in place to support the CPSWs and counsellors working in these areas.
Case story 1
Sunayana (name changed) lives with her husband, daughter and father-in-law in a small village. She is a housewife and is responsible for household chores. Besides this work, she is actively engaged in social work. She was elected as a member in the local elections, representing women and marginalised communities. This has helped her to establish her identity. She feels honoured when she is praised for her work by people, especially older people.
However, her life was not same in the past. She has faced many hardships in her life. She suffered major losses in the huge earthquake of 2015. Her younger son and four members of her family died in that earthquake. Her house was destroyed. This was devastating for her. She kept remembering her son all the time and did not show any interest in daily chores. She was deeply sad and felt irritated when someone came close to talk to her. She even felt frustrated when her husband talked to her in a normal manner. She felt annoyed in normal conversation. She spent most of the time sitting alone and could not sleep at night. She used to dream about her dead son and suddenly wake up in the middle of the night.
When Sunayana first met with the TPO Nepal counsellors, she was not ready to talk. She did not share her problems. But counsellors kept approaching her and tried to talk to her informally. They made many efforts in inviting her to counselling sessions. She said, “The counsellor visited me several times but I felt it was just her duty to come to see me and she was getting money out of it”.
Despite this reluctance, the counsellor kept trying to offer support. She visited the Sunayana’s home whenever she went to that area. She dropped in to check if she was doing well or not and invited her to come for counselling. The counsellor explained that other people having the same problem had bene fited from counselling and she was not alone. She said that these problems were an aspect of her mental health and that they could be addressed through counselling. All these efforts made the woman feel that she was taken care of. After a long time, she agreed to talk with a counsellor.
During the counselling sessions, Sunayana talked about her emotional difficulties such as stress, self-blame, fear and flashbacks. She blamed herself for her son’s death. She also shared her feeling that there was no reason for her to live in this world and her life was worthless. She told the counsellor that she had tried to take her own life − once near her house and once 5 km away, when she went somewhere with her daughter. She said that she did not find it easy or appropriate to share her fears, stresses and tension with others.
The counsellor discussed different options for dealing with emotional difficulties and offered positive ways for dealing with them. Sunayana was encouraged to engage in those activities which she found comfortable and to share her problems with trusted people. She was comfortable after these discussions. She was made aware of her positive skills and encouraged to actively engage in social work. She was also encouraged to ventilate her feelings in various ways such as keeping a diary writing and writing poems. She said that she felt easy and light when she did these things. Gradually, her social engagement increased. She accepted that her suicidal ideation was the result of severe psychosocial and emotional difficulties and she was working to find positive ways of dealing with the hardship she had faced.
When she remembers those days, she questioned herself. “Why did I do those things? I have to do many things in my life. I lost my son but there are many children who are like my son and I have to do good things for them”. She says that a damaged house can be rebuilt but the people who died will never return.
Currently, she is an elected local representative in her community and is working to support children with emotional difficulties. She has also been trained to work as a community psychosocial worker.
| Media Awareness and Advocacy | | |
People were hesitant to talk about suicide when it happened in their own homes and disclosure of suicidal ideation to family and friends was very low (Hagaman, Khadka, Lohani, & Kohrt, 2017). On those occasions when people did talk about it, they would justify suicide by highlighting social and economic problems and underplayed the psychological issues associated with it. This was a challenge which needed to be addressed in order to reduce the stigma associated with suicide. We needed one common platform where we could share our information with the broad community. We decided to use local FM radios to share information on suicide.
We felt that information should be disseminated positively, with care for how it is presented. We held a number of brainstorming sessions to discuss the name and format of the programme and finally decided on the phrase, “Banche Sansar Jitinchha”, which means “You can conquer the world if you are alive”.
We received a positive response regarding the name of the radio programme. While listening to the programme and its name, people said that they felt positive. The name and content of the programme gave people the energy to tackle emotional turbulence and convey positivity towards life. However, there were other opinions as well. Some people said that the name should be “Banche Sansar Dekhincha” (You can see the world when you are alive) and some said that we can think of winning only if we are alive. We discussed these issues in groups of adolescents, children and community members and found our name was in fact easily understood as it was similar to a Nepali proverb. So we took it forward into our programme.
The format of the radio programme was developed with consultation of technical media partner (Niharika Production) in such a way that it presented a story of an individual who had faced different problems and may have thought about, decided or attempted suicide. They were all stories of people who had survived suicide and had found a way of living their life afterwards. These stories therefore reflected the name we had chosen for the programme.
More than 30 radio episodes focusing on suicide prevention and mental health were aired, along with information on psychosocial support centres where people could seek support for psychosocial and mental health issues. The programme also had three different ‘information boxes’ with accessible information about available treatment service centres, contact points and psychosocial and mental health-related counselling and service facilities.
These radio programmes made it easier to go into communities to conduct sessions on suicide. The stories featured on the programmes helped people to talk about suicide together. The programmes dealt with many different topics including issues related to mental health, how one can deal with suicidal ideation, the role of family members, social media, and stakeholders for suicide prevention, how to care for one’s mental health, depression, etc. Schools also started to include suicide awareness in their weekly extracurricular activities and conducted programmes like essay competitions on suicide prevention.
Case story 2
Sarala is a married woman living in a family along with her son. Her husband is working abroad. Some time ago she developed various symptoms related to psychosocial problems but was not aware of it. She was frequently irritated and was unable to do daily chores including fieldwork. Her family members were so unhappy with her and accused her of being lazy. She felt that her love for her son had decreased. She kept thinking about attempting suicide. When she tried it, the thought of her son stopped her from doing so. Then she started doing self-harm to cope with these difficulties because this helped her to feel more relaxed. She was confused and could not say what was happening to her. It was a really difficult situation that she could not name.
When she listened to the radio programme, “Banche Sansar Jitincha”, she felt that it was her story being presented through the radio. She started listening to the programme and noted down the address of TPO Nepal. She called the office and started counselling. She began to understand that these problems are named psychosocial problems and that they can develop into mental illness if severity increases. She learned about positive coping and started to recognise her strengths, capacities as well as her problems. The counsellors also met her family and made them aware of her situation and the support she needed to heal. Family members then acknowledged her problem and started supporting her. She was also referred to the district hospital. After frequent counselling sessions and risk assessment she is now doing well, she loves her son very much and happy with the improvements.
| Use of Flipcharts for Psychoeducation | | |
Along with the radio programmes, a flipchart was developed to provide psychoeducation about suicide and suicide prevention. The flipcharts present eight colourful pictures and include instructions in Nepali for the facilitators using them. [Figure 1] shows two of the pictures: The first shows a person trying to bury the means of suicide in the ground and in the next picture, she is planting a tree in the same place. The second picture holds a message that suicide is preventable and new life is possible. The third picture is about difficulties and emotions in life which everyone faces. The major theme here is in normalising difficult emotions. It also highlights suicide as an aspect of mental health and that people at risk of suicide need to be referred to the appropriate services for treatment. In the fourth picture, warning signs of suicide are discussed. In the fifth picture, there are two small pictures that show our reactions when we see the two situations mentioned above. The major theme here is in discussing the myths and realities of suicide. The sixth picture represents self-care and discussion focuses on what one can do when one has suicidal thoughts. The seventh picture shows family responsibilities. As one of the crucial factors in suicide prevention is the role of family members, discussion here is concerned with how a family can look after family members who may have suicidal ideation, thoughts or have attempted to take their life. The eighth picture shows the role of the community in suicide prevention and how community members can respond to people having suicidal ideation and link them to receive support. A session using these flipcharts would end with a discussion on the local referral pathways.
| Information for Key Stakeholders about Suicide and Suicide Prevention | | |
Information sessions about suicide and suicide prevention were held for key stakeholders, including agro-shop owners (who sell pesticides and agricultural goods in the community), police, teachers and journalists. These sessions featured an introduction to suicide and its impact; identifying warning signs; myths and facts regarding suicide; the role of concerned stakeholders for suicide prevention; and referral points. Responsible reporting on suicide was also discussed with journalists. They were requested to write about suicide within the broader context of mental health and to include referral information in their reporting. These sessions achieved two goals in raising the profile about suicide prevention and response as well as establishing the role of psychosocial services in the community.
| Health Systems Strengthening | | |
Nepal has an inadequate mental health system, with no mental health and psychosocial services available in primary health care. People have to travel to the nearest city to see access services. To assist in health systems strengthening, we have provided training in suicide prevention to support counsellors at psychosocial support centres at the local level. This has also provided an opportunity to link psychosocial issues with protection issues. We have also provided financial support to people not able to buy their medication and have paid consultancy fees for specialised care. We have also supported health posts in providing medicines on the government’s essential drug list. Training in WHO’s Mental Health Gap Action Programme (mhGAP; WHO, 2008) was also conducted for prescribers working in primary health facilities under the supervision of a mental health specialist has helped. As a result of our programme, a Mental Health and Psychosocial Support coordination committee was formed in the local area to coordinate mental health and psychosocial services. This led to a reported decrease in the rate of suicide in the implemented area.
| Lessons Learnt | | |
A suicide prevention programme implemented by an agency such as TPO Nepal needs to be conducted as part of a multisectoral and comprehensive response. The role of community engagement is crucial in the response, as is the participation of local and regional partners in the face of the lack of an adequate mental health system. [Table 1] below indicates the challenges we have faced and the steps we have taken to deal with these challenges. We have learned many lessons contributing to best practice in this area.
Working together with the government’s education, health and protection unit for suicide prevention and mental health literacy in a rural part of Nepal is one example of collaborative working. This enabled our programme to disseminate crucial information about suicide and suicide prevention, normalising mental health issues and offering help in the ways that people could seek support and reducing stigma associated with this topic. The media was a key partner in our programme and was central in reaching a large number of people at the same time.
The mobilisation of CPSWs in doing home visits and the availability of trained human resources was a crucial part of the programme. Their visibility and capacity to deal with this sensitive work due to good training and regular supervision to CPSWs and counsellors contributed greatly to the success of the programme. We found that the involvement of community members in suicide prevention also helped in the referral of individuals having suicidal thoughts. This signalled an accountability within the community which was of great benefit.
Other key stakeholders were part of the comprehensive response at a local level. The role of police in rescue was much appreciated where there were no helpline numbers operating. We noted that when police were sensitised, they started dealing cases sensitively and treated cases as people with mental health issues rather than involved in criminal activity. Joint orientation with school teachers in the school mental health awareness programme helped adolescents to talk about their mental health. Raising the awareness of local elected members in suicide prevention and response has also helped in budget allocation, ownership and sustainability of the programme. At the same time, continuous follow up is needed − allocating a budget does not ensure the effectiveness of the programme.
A comprehensive suicide prevention programme is sorely needed in Nepal. In its absence, the sort of programme as implemented by TPO Nepal could be replicated in various regions thereby improving mental health outcomes. Community-based s should include advocacy, banning lethal means, sensitive reporting of suicide, community awareness, stakeholder involvement and the proactiveness of the community. The pyramid in the Inter Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings (2007) provides the basis for comprehensive services. We all seek to reduce stigma around suicide and provide services delivered with empathy and supported with good referral pathways in order to reduce suicide in Nepal.
Acknowledgements
The authors wish to thank all the service users, clients, stakeholders, community; police, teachers, municipality, protection and health cluster for their support during programme implementation. We would also like to thank all the staff members, counsellors (Ms Sita Shrestha, Ms Man Kumari Thapa and Mr. Mani Kerung) and CPSWs for their tremendous effort in saving lives. The authors are thankful to Mr Suraj Koirala and Dr. Kamal Gautam from TPO for their guidance during programme implementation.
Financial support and sponsorship
TPO Nepal thanks Australian Aid for their financial support.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Banerjee D., Kosagisharaf J. R., Sathyanarayana Rao T. S. (2021). ’The dual pandemic’ of suicide and COVID-19: A biopsychosocial narrative of risks and prevention. Psychiatry Research, 295, 113577. https://doi.org/10.1016/j.psychres.2020.113577  |
| 2. | Hagaman A. K., Khadka S., Lohani S., Kohrt B. (2017). Suicide in Nepal: A modified psychological autopsy investigation from randomly selected police cases between 2013 and 2015. Social Psychiatry and Psychiatric Epidemiology, 52(12), 1483–1494. https://doi.org/10.1007/s00127-017-1433-6 |
| 3. | Hagaman A. K., Maharjan U., Kohrt B. A. (2016). Suicide surveillance and health systems in Nepal: A qualitative and social network analysis. International Journal of Mental Health System, 10, 46. https://doi.org/10.1186/s13033-016-0073-7 |
| 4. | Hossain A. S. M. F., Adhikari T. L., Ansary M. A., Quazi H. B. (2015). Characteristics and Consequence of Nepal Earthquake 2015: A Review. Geotechnical Engineering Journal of the SEAGS & AGSSEA, 46 (4), 7. |
| 5. | Inter Agency Standing Committee (IASC). (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. IASC. |
| 6. | Kane J. C., Luitel N. P., Jordans M. J. D., Kohrt B. A., Weissbecker I., Tol W. A. (2018). Mental health and psychosocial problems in the aftermath of the Nepal earthquakes: Findings from a representative cluster sample survey. Epidemiology and Psychiatric Sciences, 27(3), 301–310. https://doi.org/10.1017/s2045796016001104 |
| 7. | |
| 8. | Marahatta K., Samuel R., Sharma P., Dixit L., Shrestha B. R. (2017). Suicide burden and prevention in Nepal: The need for a national strategy. WHO South-East Asia Journal of Public Health, 6(1), 45–49. https://doi.org/10.4103/2224-3151.206164 |
| 9. | TPO. (2020). Assessment of suicide situation during COVID-19 pandemic in Nepal. Transcultural Psychosocial Organization Nepal. |
| 10. | WHO. (2008). mhGAP Mental Health Gap Action Programme Scaling up care for mental, neurological, and substance use disorders. |
| 11. | WHO. (2011). Psychological first aid: Guide for field workers. WHO, War Trauma Foundation and World Vision International. |
| 12. | WHO. (2014). Preventing suicide: A global imperative. World Health Organization. |
[Figure 1]
[Table 1]
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