An Najah National University Faculty of Graduate Studies SUICIDE FROM THE PERSPECTIVE OF PALESTINIAN MENTAL HEALTH WORKERS By Shereen Abu Ghoush Supervisor Dr. Mohammad Marie Co- Supervisor Dr. Caesar Hakim This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of Clinical Psychology, Faculty of Graduate Studies, An-Najah National University, Nablus, Palestine. 2022 ii SUICIDE FROM THE PERSPECTIVE OF PALESTINIAN MENTAL HEALTH WORKERS By Shereen Abu Goush This Thesis was Defended Successfully on 22/02/2022 and approved by: Dr. Mohammad Marie Supervisor Dr. Caesar Hakim Co-Supervisor Dr. Sajed Faisal Ghawadra External Examiner Dr. Jamil Qaddoumi Internal Examiner iii Dedication I would like to dedicate this thesis all the people who helped in the success of this work. To begin with, I extent my deepest gratitude and thanks to my supervisor Dr. Mohammad Meri and co-supervisor Dr. Caesar Hakim. Second, I would like to thank Doctors Without Borders, that funded my thesis. This scholarship helped me in completing my graduate studies and facilitated conducting the research. Finally, , I extend my thanks to all my professors at An-Najah National University Shereen Abu Ghoush iv Acknowledgments To begin with, I thank the creator of this world for assisting me in completing this thesis. Consequently, it is dedicated to all people who supported me with their advice, love and care including my father, sister, mother, children and friends. Shereen Abu Ghoush v Declaration I, the undersigned, declare that I submitted the thesis entitled: SUICIDE FROM THE PERSPECTIVE OF PALESTINIAN MENTAL HEALTH WORKERS I declare that the work provided in this thesis, unless otherwise referenced, is the researcher’s own work, and has not been submitted elsewhere for any other degree or qualification. Shereen Abu Goush Student's Name: Signature: 22/02/2022 Date: vi List of Contents Dedication ........................................................................................................................ iii Acknowledgments ........................................................................................................... iv Shereen Abu Ghoush ....................................................................................................... iv Declaration ........................................................................................................................ v List of Contents ................................................................................................................ vi List of Tables ................................................................................................................. viii Abstract ............................................................................................................................ ix Chapter One: Introduction and Theoretical Background .......................................... 1 1.1 Introduction ................................................................................................................. 1 1.2 Statement of Problem .................................................................................................. 1 1.3 Background ................................................................................................................. 2 1.3.1 Factors Associated with Suicide Phenomenon and Its Prevalence ...................... 3 1.3.2 Suicide And Mental Health in Palestine .............................................................. 4 1.4 Mental Health in Palestine .......................................................................................... 4 1.5 Questions of the Study ................................................................................................ 5 Chapter Two: Literature Review .................................................................................. 7 2.1 Introduction ................................................................................................................. 7 2.2 Suicide in Arabic and Islamic culture ......................................................................... 7 2.3 Literature Review ....................................................................................................... 9 2.4 Conclusion ................................................................................................................ 15 Chapter Three: Methodology ...................................................................................... 16 3.1 Introduction ............................................................................................................... 16 3.2 Justification for the study .......................................................................................... 16 3.3 Aim and objectives of the study ............................................................................... 17 3.4 Sampling strategy ..................................................................................................... 17 3.4.1 Inclusion Criteria ................................................................................................ 18 3.4.2 Exclusion criteria ............................................................................................... 18 3.5 Ethical, Access and Political consideration .............................................................. 18 3.5.1 Ethical approval ................................................................................................. 18 3.5.2 Inviting participants to take part ........................................................................ 19 3.6 Data Generation Methods ......................................................................................... 19 3.6.1 Interview Process ............................................................................................... 21 vii 3.7 Data Management and Analysis ............................................................................... 21 3.7.1 Data analysis process ......................................................................................... 22 3.7.2 Recording ........................................................................................................... 23 3.8 Conclusion ................................................................................................................ 24 3.9 Trustworthiness ......................................................................................................... 24 Chapter Four: Results .................................................................................................. 25 4.1 Demographic data ..................................................................................................... 25 4.2 Themes ...................................................................................................................... 25 4.3 Summary ................................................................................................................... 36 Chapter Five: Discussion and Recommendations...................................................... 37 5.1 Discussion ................................................................................................................. 37 5.2 Conclusion ................................................................................................................ 39 5.3 Recommendations ..................................................................................................... 41 References ....................................................................................................................... 43 ب ............................................................................................................................... الملخص viii List of Tables Table 1: The demographic data of the participants ......................................................... 25 ix SUICIDE FROM THE PERSPECTIVE OF PALESTINIAN MENTAL HEALTH WORKERS By Shereen Abu Ghoush Supervisor Dr. Mohammad Marie Co- Supervisor Dr. Caesar Hakim Abstract This study aims at identifying suicide from the perspective of Palestinian mental health workers by interviewing sample of Palestinian mental health workers consisted of 16 participants through an interview includes eight questions which have been analyzed by using qualitative method. The study findings showed that: 1. Mental health workers relate reasons for suicide in Palestine to external, internal and personal pressures. 2. There are differences between males and females include social reasons, economic reasons, and violence against women, family pressures, and personal reasons. 3. In questions related to Palestinian culture, mental health workers related factors to reducing the phenomenon to cultural factors, norms and customs, national culture, Strain, religion affects and family solidarity, while they related other factors to the increasing of the phenomenon, which included political, economic, social factors and psychological stress. 4. The dangerous intention to suicide in Palestine included evaluating case feeling, needs and case surrounding. In addition, 5. Concerning the transferring procedures for suicide cases: mental health workers determined specialist's tasks and referral procedures. 6. Procedures for informing families including collecting information, communicating families and authorities, determining treatment plan and providing supporting plan, 7. The role of the specialist in suicide case intervention includes assessment, communication, transferring and seeking support, providing guidance. x 8. Suggestions to prevent suicide attempts included more research to understand the phenomena, increasing awareness towards suicide in all aspects, and providing supportive bodies and specialized centers. Implication of the study are mentioned such as training mental health workers, increasing awareness level towards suicide, and providing supportive bodies in order to decrease the phenomenon, besides future studies are discussed. 1 Chapter One Introduction and Theoretical Background 1.1 Introduction The forms of suicide include suicidal attempts plans, threats and thoughts are largely increasing in the western and eastern societies among all people from different ages. Reports on the daily news about suicide affects other’s people behaviors, as people become more violent, using more drugs and increasing their negative behaviors. (Georgiades, et al., 2019). Researches distinguish between two types of suicide: real suicide and physical death, and psychological suicide. Psychological suicide is defined as of explicit suicide, where some people are totally devoured and hated, driven by desperation to break themselves up with illness and with a closer look at the previous set of definitions. They suggest that suicide is an act or single event, but (Mann, Waternaux, Haas, & Malone, 1999) pointed out that suicide is not an isolated event. Instead, it is a complex process, and suicidal behavior can be envisioned as a reality related to latent power, including suicidal ideation and suicide contemplation followed by attempted suicide, and finally the completion of this suicide attempt. (Bonner, Rich, Kirkpatrick, & Jans, 1999) state that suicidal behavior is a complex dynamic rather than a static isolated event. According to the researchers, suicide behavior is defined as a composite process of various stages that begins with a perception of latent suicide, contemplating active suicide, then planning for active suicide. At the end, active suicide attempts accumulate in the individual and the individual's position may fluctuate in this process according to the biological, psychological and social effects. 1.2 Statement of Problem Various electronic databases have been employed in order to look for this thesis’s data including Google.ps, PubMed, Direct Science and Google scholars. English keywords included Palestine and suicide as well as mental health workers. Basically, (30) studies employed in this study highlighting their appropriateness in the review of previous studies. Facts reveal increasing in suicide and suicide attempts all around the world and 2 in Palestine. So, the statement of problem is limited to answer the question related to suicide from the perspective of Palestinian mental health workers. 1.3 Background According to (World Health Organization, 2017), nearly 800,000 people put an end to their lives, as well as many who try to commit suicide every year . Each case of suicide is a tragedy that affects entire families, communities and countries with the long-term effects those who have been left behind them. Suicide occurs at different stages of life, with the second most important cause of death among those aged 15-29 years globally in 2016. Suicide occurs not only in high-income countries, but also globally in all regions of the world. In fact, more than 79% of global suicide cases in 2016 occurred in low- and middle-income countries. Suicide is a serious public health problem but can be prevented by timely, evidence-based and low-cost interventions. To ensure the effectiveness of the national response, a comprehensive multisectoral strategy for suicide prevention should be provided (Wasserman, 2019); (Dreier, et al., 2019). Suicide in Palestine a constantly rising challenge for the Palestinian society and its various institutions. For example, the current criminal policy did not criminalize the perpetrator's act in recognition of the social and psychological dimension of suicide. The Palestinian law considers that anyone who attempted suicide committed a misdemeanor and the attempt to commit suicide is a separate crime. Despite this, the Palestinian law punishes the attempt to commit suicide, but the judicial work in the Public Prosecution has limited the case to the point of no importance in view of the futility of punishment in such cases and the maintenance of family ties (Abu Alian, 2016). According to the Palestinian Police Research Department, the number of suicidal cases reported in the West Bank rose by 14% in 2018 compared to 2017. The West Bank witnessed a total of 25 suicide cases. The report shows that 15 citizens committed suicide, 60% of all registered cases were males and 10 females (40%) in the West Bank in 2018. The previous year, 2017, witnessed 22 suicide cases. The number of suicides in the unmarried category of both sexes was 17 cases (68% of registered suicides), while the number of suicides among married couples was 8 (32%). According to the age 3 distribution, the highest rate of suicide among the age group of 25 to 28 years was 32%. As for the educational level, the highest percentage of persons who committed suicide was among the secondary certificate holders and this category represents 44% of registered cases (Department, Palestinian Police Research, 2018). Suicide or suicidal attempts by using means such as taking pills of medicine, causing wounds to the limbs or hanging themselves with the intent to commit suicide didn't reach death. Most of these cases (suicide or attempted suicide) were carried out by females compared with those recorded among males, where statistics showed that 218 people attempted suicide (Through same means previously mentioned), including 61 males and 157 females (Moutier, 2021). 1.3.1 Factors Associated with Suicide Phenomenon and Its Prevalence One of the most important causes and motives of suicide is psychological illness as people with such diseases do not seek treatment. 40% of suicides are in this category and 32% of family disputes are second to suicide. In the third place came the economic situation as a reason for the 12% of suicide cases recorded, emotional reasons (4%), and exposure to extortion, which was the cause of suicide for 4% of registered cases. The geographical and demographic distribution of suicide persons varied between towns, villages and camps, but the highest number of suicide victims was among urban residents which are 13 cases equals 52% of registered cases (Department, Palestinian Police Research, 2018). According to (Department, Palestinian Police Research, 2018), Hebron has the first place in terms of the number of suicides registering 7 cases, followed by Qalqilya Governorate with 5 cases. In the contrary, no cases of suicide have been registered in the governorates of Tubas, Salfit and Jericho. Villages ranked second with 11 cases of suicide or 44%. The lowest number of suicide cases was recorded at the refugee camps with only one case recorded, or 4% of all registered cases. Most of the suicides (76%) were by using the rope to end lives followed by falling or jumping from altitude (12%), then using poisons, weapons and sharp instruments as means to end their lives). 4 1.3.2 Suicide And Mental Health in Palestine Suicide is preventable. There are a number of measures that can be taken at the population, sub-population and individual levels to prevent suicide and attempted suicide. These include reducing access to suicide devices such as pesticides, firearms, certain medicines, preparing the media for reports in a responsible manner; diagnosis, treatment and early care for people with mental disorders, substance abuse disorders, chronic pain and acute emotional disorders. Health workers who should be specialists in the assessment and management of suicidal behavior provide follow-up care to persons who commit suicide and provide community support (Islam, 2019). Suicidal thoughts and behaviors must be prevented and managed by health professional. Confidence in caring for people at risk of suicidal thoughts and behaviors is affected by knowledge of and attitudes toward suicide (Boukouvalas, El-Den, Murphy, O'Reilly, & Salvador, 2019). The Palestinian Authority began managing many services in 1993, including the health service in the occupied Gaza Strip and West Bank. However, according to (Giacaman & Mikki, 2004), as a result of cultural and financial barriers, more patients became unable to access psychiatric hospitals. A few governmental and non-governmental agencies providing psychosocial and community mental health services, but most depending heavily on external funding. In addition, there are relatively few mental health professionals in the country. According to the World Health Organization (WHO) and Palestinian Ministry of Health, community mental health has not been a priority in the financial budget of the Ministry of Health and is under-resourced (Marie, Hannigan, & Jones, 2016). Consequently, this study will shed light on the view of mental health workers on suicide phenomenon in Palestine in order to identify causes, results, prevention and solutions for this dangerous phenomenon in the society. 1.4 Mental Health in Palestine Mental Health Unit in the Palestinian Ministry of Health since its establishment has adopted a clear strategic policy in line with the Ministry of Health policy regarding developing mental health services to be national services that are organized, 5 comprehensive and available to all. Mental health centers and institutions have been established and these centers are efficient and effective aiming for sustainability (Okasha, Karam, & Okasha, 2012). The Ministry of Health is seeking a Palestinian society with a high level of awareness of the importance of mental health, therefore, has adopted societal mental health services in order to remain patients in society and has refused to isolate and marginalize it .It has taken the initiative to add rehabilitative and functional treatment in addition to the treatments provided in mental health centers such as cognitive behavioral therapy, family therapy, psychological evaluation and checks personality, intelligence, and treatment with psychological drugs in addition to cooperation with civil society institutions and the important academic role in cooperation with universities and colleges in education and training PMH, 2020. The Ministry of Health also established the first combined mental health center for children and adolescents in Halhul in addition to the Information Documentation Center in Ramallah, with a library containing large number of books, references and electronic magazines in mental health. It is currently working on establishing a mental health center for children and adolescents in Nablus (Giacaman & Mikki, 2004). 1.5 Questions of the Study The study aims to answer the following questions: 1- What are the main reasons that lead to suicide in Palestine? 2- Is there a difference in the causes of suicide between males and females in Palestine, please explain the reasons, whether there are differences or not? 3- What is the relationship of Palestinian culture and the Palestinian context to suicide? 4- How would mental health workers evaluate the seriousness of the patient's intention to commit suicide? 5- What is the nature of the transfer procedures in the event that a suicide risk is confirmed? 6- How are the patient and his family informed of the challenges related to patient suicide intentionls? 6 7- What is the role of the mental health specialist in the intervention in cases of suicide? 8- What are the reasons for the increase in suicides in Palestine? 9- What are the suggestions about steps to prevent suicide? 7 Chapter Two Literature Review 2.1 Introduction Three steps were involved in the study. To begin with, the researcher entered the search term into the search engine as described in the following sections. Researchers read and analyzed the full text articles located in the database step two according to the title and abstract of the relevant articles. In the third step, researchers reviewed and analyzed the full text articles located in the database according to their contents. PubMed, Direct science, Google Scholar, SAGE journal, Taylor & Francis journal, AN- Najah University website repository.najah.edu, and a reference list of published papers was studied and employed to backup this section. Researchers limited their research to English and Arabic. Keywords in English included Palestinians and suicide, and mental health workers and suicide. Study about Palestinian nurses working in mental health was found, but few references were found concerning nursing suicide. In analyzing a (30) study, consideration was given to the above-mentioned aspects, such as instrument, aim, sample, data collection, limitations, and ethical approval. Further, reliability and validity were also considered for empirical studies using statistical methods. 2.2 Suicide in Arabic and Islamic culture According to Islamic scholars, suicide is the killing of a person himself, the destruction of an organ by one of its members, or its corruption or weakening in any way such as: hanging, burning, taking poisons, taking a large dose of drugs, throwing self in the river, or killing self with a drink. These are reasons that the owner believes with him that his death became better than his life (Lester, 2006). According to Islamic view, weakness of human religious belief, and lack of awareness of the seriousness of this heinous act are the major crime, which entails depriving the 8 soul of its right to life, in addition to exposure to intense promises and painful punishment in the hereafter. For true and complete faith requires a person to trust and be certain in God Almighty and to be satisfied with the judgment and worth of God Almighty, and not to object to that fate no matter how bad or unsatisfactory it appears to a person. Contentment with it. The overpowering of the mistaken belief that the suicidal person would put his suicide and his loss to himself as an end to what he lives or suffers from problems, pressures or bad circumstances. This is a wrong and mistaken concept and far from the truth (Rosenthal, 2015). Suicide is considered a major sin in Islam, and killing the soul is not a solution to get out of the problems that Satan transmits, and the obsessions that it casts in the souls, and if not after death. In the holy Quran, Allah said (O ye who believe! Eat not up your property among yourselves in vanities: But let there be amongst you Traffic and trade by mutual good-will: Nor kill (or destroy) yourselves: for verily Allah hath been to you Most Merciful! [An-Nisa, 4vs29]. Allah Almighty said “ And spend of your substance in the cause of Allah, and make not your own hands contribute to (your) destruction; but do good; for Allah loveth those who do good.”[Al-Baqara, 2vs195], and said:(Those who invoke not, with Allah, any other god, nor slay such life as Allah has made sacred except for just cause, nor commit fornication; - and any that does this (not only) meets punishment([Al-Furqan, 25vs68]. Also, the warning came in the slayings of Muhammad, may God bless him and grant him peace; Where Abu Hurairah narrated, he said: The Messenger of God, may God bless him and grant him peace, said: ((Whoever kills himself with an iron, his iron in his hand will be cursed in his stomach in the fire of hell, eternally immortal in it forever, and he who drinks a poison, killing himself, he senses it in the fire of hell immortally immortal In it forever, and whoever worsens from a mountain, then kills himself, for he will deteriorate in the fire of hell, eternally immortalized in it forever)); narrated by Muslim. 9 2.3 Literature Review Suicide cases and attempts have become prevalent in the Palestinian society. So it is imperative to analyze this phenomenon in order to identify the main factors that cause it. The following studies addressed this issue in depth. (Boukouvalas, El-Den, Murphy, O'Reilly, & Salvador, 2019) conducted a systematic review of physicians' knowledge about suicide, attitudes toward suicide and their confidence regarding dealing with suicidal people. Systematic searches have been performed on four electronic databases covering a period of 10 years. Following retrieval of 1,723 abstracts, 46 primary research publications were included, involving both cross-sectional (n = 27) and intervention study designs (n = 19). Primary health care professionals, specialists, and health care students were surveyed about their knowledge, attitudes, and confidence toward caring for people at risk of suicidal thoughts and behaviors. A number of studies investigated the influences of training and education, type of health care professional, country of practice, and prior suicide experience. Several factors, including knowledge of people at risk for suicide, attitudes toward those at risk, and confidence in providing care, shape health care professionals' behaviors and can influence patient outcomes. Continuing education on suicide is an essential part of the health care curriculum and of the continuing professional development of health care professionals. (Eynan, et al., 2015) study highlights that India accounts for the highest estimated number of suicides in the World. In 2012, more than 258,000 of the 804,000 suicide deaths worldwide occurred in India. Early identification and effective management of suicidal ideation and behavior are paramount to saving lives. However, mental health resources are often scarce and limited. Throughout India, there is a severe shortage in mental health professionals trained, which results in a treatment gap of about 90%. A comprehensive needs assessment was undertaken to identify the nature of the deficits in suicide prevention training for physicians in three Indian cities: Mumbai, Ahmedabad, and Mysore. 10 A total of 46 doctors answered the questionnaire. Focus groups were conducted in Mumbai and Ahmedabad cities with 40 physicians. Discussions were held with psychiatrists and psychiatrists in hospitals and clinics in Mumbai, Ahmedabad and Mysore. The study revealed that there are existing training gaps in health care worker suicide prevention. Existing training is qualitatively and quantitatively inadequate and poses a significant flaw in the core competencies needed to identify and treat patients with suicidal ideation or suicidal behavior. Only 43% of the doctors surveyed felt they were capable of treating suicidal-prone patients. The majority of surveyed physicians believed that they would benefit significantly from additional training to improve their suicide risk assessment and intervention skills. (Kaniwa, Suda, & Hirayasu, 2012) current knowledge and attitudes of suicide prevention between local government officials and health and social care professionals, and the impact of providing suicide prevention education on their knowledge and attitudes on suicide and its prevention. Examined. 183 local government officials and 432 health / social workers completed the survey before and after one training session. Prior to the session, local government officials and health / welfare experts showed an almost positive attitude towards suicide prevention efforts, albeit with slight differences between the two groups. After the training, the knowledge and attitude of most of the questionnaire items improved further. Respondents with one or more experiences in suicide prevention training showed significantly more knowledge and positive attitudes prior to training than respondents without such experience. In addition, knowledge of depression and sympathetic attitudes were found to be particularly associated with the general attitude of "preventing suicide". Suicide prevention training has been shown to be effective in developing appropriate knowledge and attitudes among local government officials and health and social welfare professionals who are the gatekeepers of suicide prevention. Our results confirm the importance of suicide prevention education and help creating a standard suicide prevention education program in Japan. (Talseth, Olstad, & Høifødt, 2007) took a look at purpose to shed mild at the which means of newly knowledgeable physicians' lived reports of gaining knowledge of methods associated with treating suicidal sufferers. Thirteen newly knowledgeable 11 physicians narrated their gaining knowledge of reports at the same time as treating suicidal sufferers of their very own practice. The interview texts had been transcribed and interpreted the usage of a phenomenological-hermeneutical approach stimulated via way of means of Bricoleur’s philosophy. The outcomes of the study implied a few elements associated with intellectual medical examiner while handling suicide that include (a) Being in a transitional gaining knowledge of manner. (b) Preparing for practice (Getting equipment and schooling skills, turning into aware about one's very own attitudes); (c) Gaining revel in from treating sufferers (Treating and following up sufferers over time, storing reminiscences and spotting similarities and variations in sufferers); (d) Participating within side the expert network (Being an apprentice, relating scientific memories and receiving comments, sharing feelings from scientific reports, Receiving aid from peers). It gives extra facts approximately gaining knowledge of reports of younger physicians throughout the important transition segment from scientific college to early expert life. Peers are used for each gaining knowledge of and aid and can constitute a extra effective useful resource within side the gaining knowledge of manner than formerly recognized. Emotional reports do now no longer appear to be safely targeted upon in supervision, which manifestly has relevance each for gaining knowledge of and for the well-being of younger experts. It showed a few regions of the academic gadget that might profitably be multiplied consisting of stimulating extra systematically to important mirrored image on and in practice, interest to emotions with inside the reflective manner and provision of extra overall performance comments to younger physicians. (Kishi, et al., 2014) study aims to assess the impact of a 7-hr schooling software for emergency room nursing employees in Japan. Method: In all, fifty-two nurses finished the questionnaires earlier than the workshop and 1 month after the workshop. The nurses’ knowledge of and willingness to take care of suicidal sufferers undoubtedly changed. It is viable to offer a 7-hr, pretty short, workshop on suicidal prevention aimed toward emergency scientific workforce and to enhance attitudes throughout a follow-up of one month. 12 It is unsure whether or not the nice attitudes of emergency nurses towards suicide and/or instructional interventions ought to affect the consequences of those interventions. Further research has had to cope with those vital questions on this field. (Da Sliva Cais, Da Silvera, Stefanello, & Botega, 2011) aimed to enhance experts’ understanding and attitudes towards suicide prevention. A suicide prevention schooling of 18 hours length changed into carried out with 270 fitness experts, especially, number one care workers, who had been mechanically worried with sufferers at excessive threat for suicide. Questionnaires had been used to evaluate adjustments in attitudes and understanding. The rating within side the understanding questionnaire, with 21 factors as most value, accelerated from 8.nine to thirteen factors (p <.001, importance degree of 95%). Of the 25 questionnaire objects representing attitudes, 18 confirmed huge alternates after the schooling. This schooling version has more advantageous understanding and attitudes towards suicide prevention in healthcare workers. (Bocquier, et al., 2013) attempted to explain GPs' attitudes, perceived barriers, and self- mentioned practices on this wondering of those sufferers and to research elements related to those practices. This cross-sectional survey changed into carried out amongst contributors in a panel of randomly decided on French GPs (1249/1431 participated: 87.3%). GPs had been interviewed with a standardized questionnaire masking their expert and private traits, attitudes, and practices in exploring the suicide threat in their sufferers with melancholy. The study constructed a suicide inquiry rating via way of means of summing the responses to five objects and used a couple of linear regression evaluation to discover the traits related to this rating. Most GPs mentioned inquiring approximately the presence of suicidal ideation regularly or very regularly; much less than 30% mentioned that they regularly explored symptoms and symptoms of a selected suicide plan. The suggest suicide inquiry rating changed into 12.4 (SD, 2.nine; range, five–20). False thoughts, consisting of questioning that sufferers who document suicidal thoughts do now no longer regularly dedicate suicide, had been frequent (42.3%). Previous persevering with scientific training on suicide, participation in a proper intellectual fitness network, and sufferers who dedicated suicide with inside the beyond 13 five years had been related to a better rating. Reluctance to impeach sufferers approximately suicide and belief of inadequate ability had been related to a decrease rating. This study at confirmed extraordinary variability in French GPs' practices in exploring suicide threat in sufferers with melancholy. Interventions aiming at enhancing GPs' preliminary schooling and persevering with scientific training in suicide and/or melancholy, and their collaboration with intellectual fitness experts need to be developed, and their affects assessed. (Marie, Hannigan, & Jones, 2016) take a look at discusses the excessive ranges of intellectual health experts want to discover among Palestinian people, and to examine offerings, training and studies on this vicinity with unique interest paid to the West Bank. CINAHL, PubMed, and Science Direct had been used to look for materials. Evidence from this overview is that there may be a need to growth the provision and nice of intellectual fitness care. Mental health coverage and offerings in Palestine want improvement which will higher meet the wishes of provider customers and experts. It is critical to elevate focus of intellectual fitness and growth the combination of intellectual fitness offerings with different regions of fitness care. Civilians want their simple human wishes met, consisting of having freedom of motion and seeing a give up to the occupation. There is a need to decorate the suicide and ability of network intellectual fitness teams. There is a need to growth sources and provide extra aid, updated schooling and supervision to intellectual fitness teams. In Brazil, (Silva, et al., 2015) mentioned the elements related to most important melancholy and suicide threat amongst nursing experts via way of means of an integrative overview in Pub Med/MEDLINE, LILACS, SELO and BDENF databases, between 2003 and 2015.Twenty posted articles had been decided on, in the main from between 2012 and 2014, with huge manufacturing in Brazil. It discovered that nursing experts are susceptible to melancholy while younger, married, appearing night time paintings and having numerous jobs, and once they have a excessive degree of training, low own circle of relatives income, paintings overload, excessive stress, inadequate autonomy and a experience of expert lack of confidence and war with inside the own circle of relatives and paintings relationship. 14 Suicide threat changed into correlated with the presence of signs of melancholy, excessive ranges of emotional exhaustion, depersonalization and coffee non-public accomplishment; traits of Burnout Syndrome. It concluded that suicide threat amongst nursing experts is related to signs of melancholy and correlated with burnout syndrome that may have an effect on paintings overall performance. (Almajali, 2012) carried out a take a look at aiming at figuring out social, financial and mental elements related via way of means of explaining the suicide phenomenon in Jordan. The study pattern consisted of all finished suicide cases (206) and suicide attempts (1907) amongst ladies and men in Jordan via way of means of the usage of to be had statistics within side the statistical reviews of Jordanian Public Security Directorate/Crime Information Department from (2000-2009). The study used descriptive records of means, preferred deviations and possibilities so as to research statistics and solution The study at foremost questions. It discovered that the maximum elements main to suicide are social elements, accompanied via way of means of mental elements, then financial elements, and there may be a growth of suicide prices in phrases of numbers in city regions than in rural regions. Other students consisting of (Wazy, 2012) recognized numerous concerns while explaining suicide consisting of the motives that reason suicide, the concept of explaining suicide phenomenon and most important motives for suicide and minor ones via way of means of reading numerous literature reviews. It discovered that suicide is a self- decision, violence in the direction of self and alarm for the encircling context, escaping from a few occasions that the character could not encounter. It discovered that suicide related to biological, social or mental elements. (Ohtsu, et al., 2009) studied the superiority of suicide loss of life in Japan, displaying that it has persevered to be excessive and is a urgent social problem. In their take a look at, the ratios of the variety of suicide loss of life in line with day, via way of means of day of the week, and in week days relative to vacations had been calculated the usage of the statistics for all suicide deaths recorded till 2009. They calculated the suicide loss of life ratios amongst women and men in every age and additionally amongst the ones of efficient age. The study discovered that the variety of suicide deaths recorded in line with day on Mondays is 1.five instances than that on vacations amongst men. This shows that the shape of the painting’s week might also additionally probably affect 15 suicide deaths amongst men. The authors concluded/endorsed that destiny discussions concerning the association and distribution of weekly vacations need to be carried out which will lessen the variety of suicide deaths. (Hawton, Rodham, Evans, & Weatherall, 2002) mentioned suicidal phenomena (suicide attempts, planned self-damage and suicidal plans, threats and thoughts) are not unusual place in adolescents. Identification of things related to those phenomena ought to play an vital position withinside the improvement of college or network-primarily based totally prevention and intervention programs. In this article, the researchers mentioned the outcomes of a scientific overview of the global literature on population-primarily based totally research of things related to suicidal phenomena in adolescents. These elements embody psychiatric, mental, physical, non-public, familial and social domains. It is apparent from the preceding research that every one of them have the equal goal that's the elements related to suicide loss of life with inside the groups that's the equal goal of the prevailing take a look at. Lack of Arabic research approximately suicide specifically within side the Palestinian context changed into one of the vital to behavior of the study at, so, this takes a look at will cowl the distance of this scarcity in research via way of means of seeking to apprehend the suicide phenomenon from the angle of intellectual medical experts in Palestine. 2.4 Conclusion This chapter has clarified the historical improvement of the idea of suicide. Since then, the suicide idea has turned out to be greater described or defined in keeping with its use and wherein context. Various research's had been then added to explain suicide and its exam outside and inside the mental health field. The literature evaluate carries few resiliency studies research carried out inside the Palestinian cultural context. After those first chapters (advent and literature evaluate) that have mentioned suicide, the following chapter will talk the followed technique together with pattern selection, how the statistics changed into gathered and analyzed. 16 Chapter Three Methodology 3.1 Introduction This chapter will cope with research process issues in details. It includes numerous sections: justification of this study, goal and objectives, studies layout and methods, sampling strategy, and sorts of generated data. The bankruptcy consists of a dialogue on making use of for formal medical and moral approval from the school of graduate research at An Najah National University. This consists of securing approval from the research review and ethics committee. It consists of an account of negotiating get entry to intellectual fitness workers. The use of interviews is offered in detail. Data management, analytic processes, and techniques to decorate the first-rate and objectivity of qualitative studies are discussed. Finally, the significance of reflexivity is discussed. 3.2 Justification for the study As described in the previous literature review chapter, there is a gap in the literature investigating suicide from the Perspective of Palestinian mental health workers. According to the Palestinian Police Research Department, the number of suicidal cases reported in the West Bank rose by 14% in 2018 compared to 2017. The West Bank witnessed a total of 25 suicide cases. The report shows that 15 citizens committed suicide, 60% of all registered cases were males, and 10 females (40%) in the West Bank in 2018. The previous year, 2017, witnessed 22 suicide cases. The number of suicides in the unmarried category of both sexes was 17 cases (68% of registered suicides), while the number of suicides among married couples was 8 (32%). According to the age distribution, the highest rate of suicide among the age group of 25 to 28 years was 32%. As for the educational level, the highest percentage of persons who committed suicide was among the secondary certificate holders, this category represents 44% of registered cases (Department, Palestinian Police Research, 2018). Finally, there is also a significant gap related to studies conducted in the new social ecological tradition of suicide research especially in the mental health field. The study is significant due stressors which may include factors such as parental divorce and other difficult life events and environmental factors. Hence, this study is guided by two reasons: First, it is the researchers’ hope that the findings of this study would lead to effective strategies for 17 encountering this phenomenon. Second, it is hoped that the findings of this study will be of practical implications especially for decision –makers among academics, mental health workers, social workers and media in Palestine. 3.3 Aim and objectives of the study To explore Suicide phenomenon from the Perspective of Palestinian mental health workers, the study will try to achieve the following objectives: • Identifying the main causes that lead to suicide in Palestine. • Identifying the differences in the causes of suicide between males and females in Palestine, and the reasons for the presence or absence of differences. • Identifying the role of Palestinian culture, the Palestinian context, and their relationship to suicide. • Identifying ways to assess the risk of the patient's intent to commit suicide. • Identifying the diversion procedures followed in cases of risk of suicide in Palestine. • Identifying ways to inform the patient and his family of the challenges related to committing suicide. • Evaluating the role of the psychologist in intervening in suicide cases. • Identifying the reasons for the increase in suicides in Palestine. • Identifying steps to prevent suicide in Palestine. 3.4 Sampling strategy Purposive sampling was utilized in this study, (Welman & Kruger, 1999) explained that in phenomenological researches, the phenomenon dictates the method including the type of participants. Purposive sampling is considered the most important kind of non- probability sampling to identify the primary participants. The researcher selected the sample based on participants who have had experience with the phenomena. Participants were chosen from health care professionals who have first-hand experience in working with the participants and they were selected on purpose to answer the study objectives. Purposeful sampling was used. Purposeful sampling was used to select three different mental health workers to answer the study questions. 18 The study population consists of all mental medical experts in mental health centers allotted in Palestine. (10) Participants turned into decided on from intellectual fitness facilities allotted in Palestine. Random sampling turned into used, non-formal communiqué with one nurse from every decided on turned into recorded, and the chosen mental health workers helped in deciding on and alluring the rest of the organization members. All conferences had been audio recorded in any case participants’ verbal agreements. Participant’s inclusion/exclusion standards had been as follows. 3.4.1 Inclusion Criteria This study included full time mental health workers, their work is associated with suicide phenomenon and its prevalence in the Palestinian society. 3.4.2 Exclusion criteria This study did not include the following: • Volunteer mental health workers. • Part- time mental health workers. 3.5 Ethical, Access and Political consideration In every stage of the study, ethical and political issues have been considered. It is accepted as true with that this study precipitated no recognizable bodily or mental harm to the participants. Participants proper of autonomy, privacy and confidentiality in every period of the studies have been included. Participants have been unfastened to determine on whether or not or now no longer they wanted to take part; there has been no pressure in any manner to enroll in the study. Pseudonyms have been used to protect the information of the interviewees. The audio recorded interviews have been stored in password-protected computer systems and different collected resources have been saved in the locked office drawer. Access to the collected facts changed into limited to the research. 3.5.1 Ethical approval In 3rd of January 2020, Ethical approval was granted by An Najah National University. The researcher provided participants with written information sheet providing them with an overview of the study and its aim, informing them about the voluntary nature of 19 the study and confidentiality. The participants signed the consent forms and returned them to the researcher. Information gathered was managed and centralized in one file that no one accessed except the researcher and research supervisors. All recorded interviews were kept confidential. Privacy and confidentiality of the provided information were guaranteed, no names or any identifying information of mental health professionals or centers were revealed. 3.5.2 Inviting participants to take part Regular contact and suitable arrangements with the local managers of the facilities had been made. Community mental health workers taking part withinside the study had been fully knowledgeable of the motives for his or her participation and there had been no diagnosed costs, dangers or benefits involved. Participants have been knowledge that there had been no direct blessings for them taking part with inside and have had a look at and what they stated could be used for instructional functions only. Pseudonyms had been used for the names of all of us and places, and those had been inserted into the dataset on the earliest possibility and earlier than statistics become analyzed. It becomes defined to the individuals if someone determined to withdraw earlier than outcomes from the have a look at had been reported; the statistics could be destroyed and now no longer used at all. If a player withdrew after the thesis become completed, or after statistics become utilized in magazine articles or presentations, then it' now no longer be utilized in any similar articles or presentations. 3.6 Data Generation Methods Interviews had been selected as a method of producing information for lots reasons, which includes that they provide rationalization of under-defined experiences. They additionally gain excessive reaction rates, deliver extra understanding, permit deep verbal exchange and permit for intensity of solutions in reaction to analyze objectives (Schultze & Avital, 2011). Approval for data collection was granted by permissions obtained from the Palestinian Ministry of health in Nablus. A letter will be given to each mental health worker to take their signed consent. Obtain the IRB Report of Action (ROA) - from the Office of the Institutional Review Board at An-Najah University. Mental health workers were informed about the purpose of the study before conducting the interview through an 20 information sheet that explained ethical considerations as confidentiality, voluntary participation and their role. In-depth semi structured interviews were utilized as the main source of data collection to understand: 1. Identifying the main reasons that lead to suicide in Palestine. 2. Determining if there a difference in the causes of suicide between males and females in Palestine, please explain the reasons, whether there are differences or not. 3. Discussing the relationship of Palestinian culture and the Palestinian context to suicide? 4. Identifying how would mental health workers evaluate the seriousness of the patient's intention to commit suicide. 5. Defining the nature of the transfer procedures in the event that a suicide risk is confirmed. 6. Discussing how are the patient and his family informed of the challenges related to patient suicide intentions. 7. Identifying the role of the mental health specialist in the intervention in cases of suicide. 8. Discussing the reasons for the increase in suicides in Palestine. 9. Discussing the suggestions about steps to prevent suicide. An interview guide consisted of open-ended guiding questions on suicide in Palestine was evolved via way of means of the researcher primarily based totally on literature overview. Focus organization is a sort of in-intensity interview, and it was more appropriate for use while the objectives have been to higher know-how the experience or phenomenon, due to the fact the dialogue is greater green to benefit statistics how human beings think, experience or the act (Freitas, Oliveira, Jenkins, & Popjoy, 1998). Data was collected in depth via semi-structured interviews that consist of items that assess factors associated with suicide phenomenon and its prevalence from the point of view of mental health workers in Palestine. Therefore, the researcher designed questions that had been thorough and meant to seize the essence of the enjoyment of the participants. The interview questions had been designed to benefit understanding on the 21 primary reasons main to suicide, gender variations, and suicide, dating among culture/context and suicide, suicide danger assessment, intervention tactics followed, the position of intellectual fitness specialists, and suicide prevention. Interviews took place at participant’s work settings; each interview lasted for 45 minutes and was audio- recorded with participants’ consent. 3.6.1 Interview Process The start sheet helped to hold the interviews aiming to reply to the studies questions (McCracken, 1988). The interview manual become organized earlier than the interviews and it centered on suicide from the belief of intellectual fitness workers. The open- ended questions have been derived and advanced with the aid of using drawing at the suicide principles mentioned with inside the literature assessment chapter. These pre- deliberate questions have been reviewed, rephrased, and reorganized to be higher understood with the aid of using the participants. The researcher’s reports of investigating suicide in Palestine stimulated the layout of those set-off questions consisting of AL Ajarma (2010). These manual interviews have been organized after in- intensity discussions with the 2 supervisors. As the interviews have been performed with inside the Arabic language, underneath pre-deliberate questions or activities have been translated to Arabic. 3.7 Data Management and Analysis (Braun & Clake, 2006) thematic analysis method turned into selected to research the data. It is appropriate and suitable in shape with the followed interpretive qualitative method to reap the cause of this have a look at for lots reasons. It allows the special and rigorous description of assets of resilience for members inside their culture. It is likewise flexible; and lets in for psychosocial interpretation of findings (Braun and Clarke, 2006). It is a powerful method for looking at subject matters with inside the generated data (Bryman, 2016). I targeted figuring out subject matters/styles of residing reviews and conduct amongst members. Themes are formed by data, which might be grouped around a crucial concept or idea that reap the study's objectives (DeSantis & Ugarriza, 2000). The above analytic method can be “a technique for figuring 22 out, analyzing, and reporting styles (subject matters) inside data” (Braun & Clake, 2006, p. 6). 3.7.1 Data analysis process The contents of the audio-recorded interviews have been transcribed, and observational discipline notes in complete have been written up. The generated records (transcribed interviews, discipline notes, and amassed written files) have been coded. The records became coded with the intention of rearranging the records into categories, which facilitated comparisons, connections, grouping and evaluation later on (Maxwell, 2012). These codes and records have been collated in order to generating an preliminary set of sub-issues. These codes are applicable and gave which means to the studies goals. There have been varieties of codes used. The first kind became to focus on exciting extracts from interviewees. The 2 kinds interpreted the means of those extracts and to try and recognize what individuals supposed (Maxwell, 2012). The sub issues supposed that collected the applicable codes collectively into ability issues. Further revision of those preliminary sub-issues brought about a very last set of great improperly described issues. The produced subject matter is a class identified via way of means of the analyst within side the uncooked records and constructed via way of means of codes and subthemes. Themes offer fundamental knowledge of the records which can make a contribution to the findings (Bryman, 2016). Finally, an in-depth thematic file became produced deciding on compelling extract examples, studying those examples, and concerning this very last evaluation to the studies goals. 1) In step one, I examine and reread the generated records (transcriptions of interviews on software program, discipline notes and written files on tough copies) line via way of means of line to familiarize myself with the material. 2) In this step, the preliminary codes have been generated: something vital is stated and associated with the studies goals. Exciting capabilities have been highlighted and writing down preliminary notes of what would possibly likely have which means the applicable extracts which gave which means associated with the studies goals have been 23 additionally highlighted and named (codes). These codes defined the resilience reasserts and environmental demanding situations amongst nurses. The software program textual content records of the transcribed interviews via way of has been highlighted means o the usage of one-of-a-kind shades on phrase programmed. the hardcopy of the written files and discipline notes manually have been highlighted via way of means of the usage of colored pencils. 3) In step three, feasible sub-issues have been looked for: the applicable codes from every records have been extracted source (interviews, discipline notes and written files) and positioned in software program tables on computer. These codes have been collected and grouped collectively into ability capabilities called (sub-issues). 4) In step four, the recommended sub-issues have been reviewed: If the collected codes have been checked and reviewed applicably to the recommended sub-issues. Some codes geared up collectively and different sub- issues have been recorded and reviewed again. The feasible sub-issues have been subtle and determined if the collated extracts had fashioned a logical which means. The applicable sub-issues have been collected and grouped collectively to tell the primary issues. 5) In step five, the sub-issues/issues have been subtle and named: the sub- issues/issues have been renamed and redefined to make experience of the complete tale of the records. 6) In step six, the sub-issues/issues have been translated from Arabic into English. 7) In step seven, the very last file of evaluation is provided to make experience of the general findings. 8) At the give up the records have been reviewed to seize any records associated with the recommended foremost issues. 3.7.2 Recording To additionally enhance the reliability, audio recorders have been used to file all interviews. A local Palestinian accomplished transcriptions withinside the colloquial language (neighborhood Palestinian dialect), and he or she made comparisons among the 2 recorders to verify accuracy and reliability. The transcription becomes carried out for the primary recorder then as compared with the second recorder. Then, I checked and reviewed each unmarried phrase and, a line via way of means of line, the transcription withinside the first recorder. Then, I compared each unmarried phrase with the second recorder to verify the accuracy and reliability. Recording and transcribing interviews has a few benefits such as, it offers the possibility to look at individuals' solutions through repeated listening. Also, it minimizes the researcher's barriers that 24 might, for example, vicinity a specific which means on what an interviewee stated after the interview. It facilitates with inside the evaluation method via way of means of revisiting the audio information of the researcher or different researchers. Transcribing and checking transcription becomes a time-ingesting method (Bryman, 2016). 3.8 Conclusion This chapter has centered on the study's technique. It began out with a cause for the study at, accompanied via way of means of the presentation of a fashionable intention and particular studies objectives. It has additionally contained a dialogue on the usage of qualitative layout and techniques to generate data. The bankruptcy has contained a justification for the usage of interviews, statements, and amassing files in the investigation. The specific energy of interview techniques become mentioned and the usage of qualitative techniques to take a look at resilience become provided. The bankruptcy has additionally provided the technique of moral approval and access to the network intellectual medical experts to generate information. There have been additional discussions associated with sampling, information control, and analysis. The section has ended with sections on reflexivity and a way to sell quality, validity, and reliability in qualitative studies. 3.9 Trustworthiness In qualitative research, credibility refers back to the truthfulness of the inquiry’s findings (Ary, Jacobs, Irvine, & Walker, 2018) The researcher need to constitute the records as it should be as feasible; interviews had been transcribed verbatim to assist the reader apprehend the contributors’ world. Bias is feasible in qualitative studies, to govern bias from occurring, the researcher used reflexivity, that is self-mirrored image to perceive one's very own bias and are seeking them out (Ary, Jacobs, Irvine, & Walker, 2018). The researcher used contributors’ costs to reveal the direct connection among findings and records collected. Through descriptive adequacy, the researcher endeavored to offer correct descriptions of the contributors to help the reader in figuring out transferability (Ary, Jacobs, Irvine, & Walker, 2018). To assist with transferability, the researcher used reactivity, with the aid of using describing biases via a reflective declaration and offering precise interview questions. To set up dependability, the 25 researcher used an audit trail. This will permit others to decide how selections had been made. The researcher saved prepared notes at some stage in the records series process Chapter Four Results This chapter presents the results of qualitative thematic analysis of 16 interviews conducted with 16 mental health professionals on the topic of suicide in Palestine. The results are presented in the form of themes, each theme is explained and quotations from participants are used to support clarity and trustworthiness of themes. 4.1 Demographic data The study included 16 participants (number, gender, age range, educational level, specialization, years of experience, work setting). Table (1) shows the details: Table 1 The demographic data of the participants Variable Frequency Percentage Gender Male Female Age Less than 30 More than 30 Educational level B.A M.A and more Experience Less than 10 years More than 10 years Work setting Governmental Private Total 16 100.0 4.2 Themes Theme 1: Mental illness and socioeconomic reasons as the main causes of suicide in Palestine Participants identified mental health conditions (e.g., depression, schizophrenia, and bipolar disorder), social pressures (family, community) and economic pressures (poverty, unemployment) as the main reasons behind suicide in Palestine. Other reasons identified, were political reasons related to Israeli occupation. Participants explained 26 that all these reasons combined make up compound reasons that cause suicide in Palestine. "In the Palestinian context, and due to economic conditions, depression, the category of people with psychological disorders or problems that are medically diagnosed, whether depression or bipolar, " (Participant 7). "Social conditions, financial conditions, the political situation and the Israeli occupation, social conditions stress people because of the economic conditions. People are raging with each other because there is no room for people to protest. Diseases have a good percentage of suicide because 10% of suicides suffer from schizophrenia and up to 10-7 of the depressed patients committed suicide" (Participant 3). “A community that has gone through many complicated stages, not simple reasons, in most cases there are many reasons, and most importantly, I see the psychological reasons, such as disability, remorse of conscience, self-flagellation, law self-esteem. Suicide is not as simple, as things are complex, they are complex to the extent of its ability to deal with circumstances, with life and with the outside world.” (Participant 4) Theme 2: Gender differences in rate and reasons of suicide Participants explained that based on their experience and not formal statistics, there are differences in suicide rate and reasons between genders. Majority of participants stated that there are more males who commit suicide, while more females who attempt suicide but don’t succeed. The reasons of suicide also differed based on gender, more males seem to commit suicide due to economic pressures that cause loss of hope and despair, and more females commit suicide due to social and family pressures, as females are more exposed to violence, have less satisfaction with their life and role in community, and lower self-confidence. "Regarding males, the suicide rate is double compared to females, and the percentage of females who attempt suicide and succeed is much more than the percentage of males who commit suicide, but in the end the percentage of female suicides is lower than males" (Participant 3). 27 "Males are exposed to economic conditions. They have some control over their emotional and psychological state. Males may be exposed to situations when they may go through depression, anxiety or guilt. For example, when there is no job, there will be no money. This makes one reach the point of losing hope in life and as a result reaching the point of seeking towards suicide. " (Participant 1). "Regarding males, the reasons were due to social pressures, social expectations required from the male, and the financial conditions" (Participant 7). "For females, the reasons are most likely related to their social and family problems" (Participant 2). “Regarding girls, the reasons are more likely related to dissatisfaction with life and their role in society, lack of self-confidence and feelings of inferiority” (Participant 5). Theme 3: Compound context bound factors of suicide Participants explained that there are a number of compound and complex factors unique to the Palestinian culture and context that lead to suicide. These factors are the result of the complexity and uniqueness of the Palestinian context, and may not be found in this combination in other countries according to the participants. Some of these factors were explained as socio-political factors, while others were culture and tradition related. Political factors and living under occupation, were emphasized as being unique to the Palestinian context. Participants explained that living under occupation has its impact on all aspects of life, whether it’s economic, control of resources, limited geographical space, and constrained freedom of movement. It also affects the meaning of life and seeing a future which leads to disparity. Few participants indicated that as a result of this complexity, cultural, religious and patriotic concepts overlap and some of these concepts as “Jihad” can resemble suicide. Other cultural factors included stigma towards mental health conditions and the way women are raised and treated in a masculine society. As for the economic factors, these related to unemployment, and consumerism. 28 "There are many reasons related to the Palestinian society, and they may be related only to the Palestinian context, because suicide is two parts: a psychological part such as feelings, thoughts, events or things that are related to the self from our experience until adolescence. Second, social factors which can be related to psychological factors in any other country, …but in Palestine, there are many causes such as, poverty, difficult living conditions, economic and political conditions, the existence of occupation… and many reasons". (Participant 4). "As for the Palestinian situation, we have the occupation, and we have a big problem in controlling our economic resources. Most of these matters are in Israel's hands, even the tax clearance when it wants to suffocate us, and because of this the economic situation harms young people, I can't find a job and many people are unemployed"(Participant 3). "The bad economic conditions cause people to lose confidence in society, lose self- confidence, and feel as a burden on the parents. The treatment possibilities for us are not enough. If any patient says I want to commit suicide, and when they are transferred to the hospital, the hospital returns them in order to avoid registering their name on the insane registry. This is a bad thing that happened to me personally, and to more than one patient, I referred them. They told them during registering them, tomorrow, your name will be among the insane records". Most of the time, this treatment leads to suicide among young psychological patients” (Participant 3). "The pattern of education, and how we want to treat women and men, it is a more patriarchal society. In the same place, we have the weakest side, which is the women" (Participant 6). "Occupation, the occupation authorities, the pressures on the youth, the increase of the unemployment rate in Palestine and the difficulty of economic life, also the space we as Palestinians are limited in a very narrow geographical space and we may link it to suicide as indirect causes of suicide" (Participant 7). "The Palestinian society has reasons that are linked to customs, traditions and religion that encourage suicide. The Palestinian culture is linked to a specific link with the idea of jihad, which dominates thoughts of suicide, and these thoughts may turn if they are 29 not directed differently into cases of suicide, then thinking becomes directed to thoughts in which there is a form of suicide" (Participant 2). Theme 4: Suicide Risk assessment criteria Participants described steps they follow to assess the risk of suicide, they explained that this assessment is based on the level of seriousness or severity of the situation and includes the following levels: Level 1: Intention and motive, during this level, the seriousness and severity of patient’s thoughts and feelings for suicide are assessed, and whether the patient has a clear plan of suicide, also overruling factors as emotional blackmail and attention seeking. Level 2: Previous attempts, a consideration if previous attempts of suicide existed and if there is a family history of family member’s suicide. Level 3: Preparation and readiness, if the patient has a clear plan for suicide including, tools and place, letter of suicide. Level 4: Condition of the patient, if the patient is known to have a mental health condition and the degree of severity of his condition at this moment, in addition to the severity of the crises he is going through. Participants also emphasized that although at times it can create a dilemma to assess the risk of suicide but this matter is always taken seriously and relevant procedures for safety are immediately put in place. "Suicide has several levels, the first level is the presence of the intention to commit suicide, the second level is the attempt to commit suicide, and the third level is the preparation. I mean how do I prepare for suicide by setting a date in a specific place. Usually, People pass through crises, whenever these crises become more serious, people start to lose meaning of life. People lose the ability to face challenges, whenever people find it more difficult to adapt with life and culture, they seek committing suicide” (Participant 2). "We should imagine the risk and evaluate it, how serious the patient is. We want to assess the patient's seriousness about committing suicide. The patient has previously said and stated that I want to commit suicide. The patient has previously attempted 30 suicide several times, the more attempts the more risk. The patient prepared the suicide tools and hid from his family, or if the patient told any of his friends that I intended to commit suicide, or if he left a message in which he tells after he committed suicide about the cause of suicide and about the motives that led him to commit suicide, surely, he will be in a loss of hope, he will be in a loss of confidence that someone wants to help him. For someone who loses hope, for someone who loses confidence, for someone who reaches to this point, surely he is more likely to commit suicide because he has reached the maximum in this situation, the situation must be taken very seriously, and everything should be taken in consideration even the burden or the double risk for us" (Participant 3). "In the beginning, I evaluate the thoughts or feelings that the patient talks about, I try to understand his pain, his presence, his motives, so that I understand how real it is, sometime, some individuals, also use suicide and suicidal thoughts and express them as emotional blackmail behavior for the other party, and this thing leaves you in a dilemma, and this is a life responsibility, and it affects the therapist greatly. I myself, try to understand who the person is…. How real it is, then I can assess what I am going to do with this patient" (Participant 4). "What increases the risk factor, is any previous attempt, or history, or if someone in the family died due to suicide, the ability of this person to face life pressures, psychological resilience may affect this, many things may increase the risk factor, if there are any suicidal in the family of this person, the ability to face pressures which may increases the risk of committing suicide or not" (Participant 6). "In case that the desire or serious attempts to commit suicide are confirmed, the action is through enabling the support network close to this person to protect him to correct the relationships affecting him. The psychiatrist is more involved in this matter" (Participant 7). Theme 5: Referral procedure depends on level of risk Participants reported that referral procedure depends on level and degree of identified risk. If its level one low risk, the health professional communicates with the patient to understand his intention and reasons for suicide and assesses the risk, also during this 31 level the family is asked to monitor the patent 24 hours for few days till risk subsides. If the risk is higher and considered level two, then more than one support person is identified and it’s recommended that the patient is admitted to the hospital, in case the family refuse then they have to monitor the patient for 24 hours for few days with continuous risk assessment, and if its high-risk level three then drastic measure have to be implemented and the patient is referred to the hospital or a specialized mental health institution. Participants also mentioned that the procedure depends on the position of the mental health professional, as psychiatrists refer directly to the hospital, while psychologists consult with their supervisors regarding the best procedure to follow. "Depending on the risk level, I mean one level has procedures, the second level has different procedures, the first level is the intention to communicate with this young man, we specify the reasons, we talk and we make an assessment for the level of risk. The second level is more dangerous, more serious, or more than one supportive person. At the third level we take more severe measures. The issue becomes more serious than is officially transferred to one of the institutions that treat these cases" (Participant 2). "I ask for someone from the family, it is necessary for someone from the family to intervene with us. Then, the suggestion is that the patient enters the psychiatric hospital. Usually, the parents refuse to admit the patient to be hospitalized, then we want to ask the parents to pledge that they will watch him twenty-four hours for two or three days, then they should come again and we make the suicide evaluation. The patient is supposed to do risk assessment every day, and if the family is refusing hospitalization, it should monitor the patient for 24 hours, because at any hour the patient may escape and he may commit suicide" (Participant 3). "As a psychologist, I communicate with the administration with the direct supervisor with our rapid assessment of the situation. What we follow after that is his reference, and I go for what the counselor goes for with the manager and the supervisor" (Participant 5). 32 Theme 6: Direct communication and honest share of information and risks with families Participants explained that they utilize direct communication with families, through which they honestly share information regarding risks and explain family’s role in monitoring and providing support. As with patients they are more focused on professional’s role in supporting the patient and helping him to control suicidal thoughts. "Frankly, there is nothing better than being frank, that you want to tell them the information that you have received. Of course, you will tell them your son told me this …., and in this case there is no place for us except that we refer him to the hospital to be under observation for twenty-four hours. If they do not want him to be hospitalized, they want to provide twenty-four hours observation for him , I do not think they have a bodyguard who will watch the patient twenty-four hours until the risky process ends and we find that the patient has changed his mind" (Participant 3). "We are trying to explain for the families, and to understand the suffering, and of course we show the parents that we can help and that we cooperate with each other. Of course, we tell them about how the issue is serious" (Participant 1). "These are many levels; each level requires intervention in a certain way. I am close to the first level in which we maintain the patient's health, when these are just ideas, and we try to help the patient control his thoughts, and we try to reduce the severity and danger of these thoughts. In the second stage, we communicate with parents who need permanent monitoring people for twenty-four hours until we provide the patient with protection and security" (Participant 2). "Suicide behavior is dangerous because it is attached to life. In these cases, I mean, I don't think that anyone with suicidal tendencies has a sense of danger, because when he wants to end his life, why does he want to do that? Then, one of the many things that I hear is the meaning of life, and they reach suicide, which is the feeling of guilt. I work on the meaning of life or the feeling of guilt. I try to get the patient to deal with it. I think that I will have an effect.... but what I explain to him is the seriousness of the matter. I mean... not how I feel it is implicitly understood that it is dangerous as a patient with tendencies. Try to understand the situation by understanding the need by 33 understanding that a person may do behaviors that harm his condition, so that we can cooperate with each other to help him improve what is hurting his condition and try to communicate with them, explaining the picture and the risks, or it is possible for them to end his life. Talking has no meaning, but these things have meaning, and you must take a clear position without prejudices" (Participant 4). Theme 7: Role related to psychological intervention, follow-up and raising awareness Participants explained that their role is mainly related to providing psychological assessment and intervention for patients, evaluating degree of risk and putting a safety plan, and hospital referrals. As with families, supporting families, interventions with families of patients who committed suicide to reduce trauma, in addition to a role in raising awareness towards risk factors. "It is a disease that we want to treat, and we want to follow up this case" (Participant 1). "The evaluation is to be able to determine the level of risk, secondly in the field of intervention with the family in case of suffering, we reduce the impact of this issue because suicide is also a shock to the family and society, to the family as a community unit and it needs intervention for an unexpected shock and it also causes psychosocial illness" (Participant 2). "My role in the intervention is that if I need to refer to a hospital, I will refer, and if I do a psychological intervention and make a safety plan, I can use it at any time. If these thoughts return to him, or trying to commit suicide again, my role requires that I make an intervention for the family or supportive people, we do more awareness, the situation of the person if aware or not, he needs help, and how necessary to be present with him" (Participant 7). "The psychiatrist's role is an essential role in the evaluation and treatment. If you ask about suicide many times and the patient is concerned, someone can help and frankly ask for help. If you open the issue with him and he will open up and many patients respond to the support that the doctor gave them and give up the idea of suicide while you overlooked the question about suicide, you overlooked it many times when you see the patient might commit suicide, the role is an essential role if you do not take the initiative to ask the patient, you will lose the patient" (Participant 3). 34 Theme 8: Socioeconomic, COVID-19 & political reasons for increase in suicide rate Participants indicated a number of reasons behind the increase in suicide rates in Palestine. These reasons included economic factors in the first place. Issues related to economic pressures, poverty, unemployment and the change to materialistic and consumerism lifestyle of the Palestinian society, were identified by participants as the main reasons behind the increase in suicide rate in Palestine. Other factors were related to social problems and pressures e.g., difficult social relationships. Next to socioeconomic reasons, participants explained that political circumstances of living under occupation is a major factor that leads to suicide. Another important factor related to the Palestinian society is the lack of awareness and stigma towards mental health conditions and services (psychiatric and psychological services) and lack of awareness of sigs of suicide. In addition to shortage in mental health services, especially services that provide protection and intervention on 24 hours’ bases. In addition, of course the unprecedented factor of COVID-19 and its consequences as lockdowns, unemployment and economic hardships. "The entry of a consumerist and materialistic style into life" (Participant 1). "The lack of awareness of suicide indicators, the lack of health services that can deal with these cases and the provision of such services or providing them for 24 hours, and the third thing is the societal view of psychiatry and psychotherapy, and the resort to charlatans and the elderly have increased the problems" (Participant 2). "The political and economic conditions, and of course, the occupation is responsible for all these conditions, and we forget that we have had the Corona virus, and recently, the Corona pandemic came upon us, and the severe closures that followed, so many workers could not work for up to 7 months due to these closures, which led them to sacrifice everything including their life" (Participant 3). "Poverty, difficult conditions, poor social relationships, stress, lack of adequate mental health" (Participant 5). 35 "During Corona, the numbers have increased significantly, and the closures and pressures that were not present before on these people have increased, the chance has increased that there will be more numbers of suicides" (Participant 6). Theme 9: Prevention through raising awareness and better mental health services Participants explained that prevention of suicide is best achieved through raising community’s awareness on mental health and suicide. They also emphasized the role media should play in this regard. Another important aspect in prevention that participants discussed was proper diagnosis and intervention of mental health conditions and the importance of integrating mental health services in public health and general hospitals. "The concerned authorities should pay more attention to the media, and they should be professional in dealing with this situation, and how the media deals in favor of the problem and not to solve the problem and for community awareness. We provide available services at all levels and also integrate mental health disease with public services, hospitals, etc., and increase the quality of these levels" (Participant 2). "Diagnose is number one, suicide cannot be prevented if we do not diagnose it correctly. If it was diagnosed properly, we should try to set the patient under monitoring either in the hospital or any other place which can provide this monitoring for 24 hours, until the patient responds to the treatment, or changes his mind regarding suicide. We provide treatment for the mental illness that patients suffer from, in such cases, we give psychological treatment as soon as possible" (Participant 3). "Awareness should be spread at the widest level. We change our thinking about suicide and have more responsibility. We understand what suicide means more. We don’t associate it with weakness and failure. We focus a lot deeper than this. The individual who has suicidal thoughts, we don’t want to hear that someone is virtuous as he is in paralyzing depression, looking at depression as a cup of tea, I mean, I am depressed, so we are done about the issue of awareness in society about suicide. I also think I will tell you. Even I am a psychologist. I am facing difficulty, not only in my field, even in personal life. It is important that there are educational and scientific articles about these topics. It is very important that I accept things. I have always seen them in English. If I 36 want to read, I must be full of information. There must be a scientific work on this topic" (Participant 4). "There should be more work with the family, it is specifically for people with personal disorders or psychological problems. We do not have the necessary or appropriate awareness to seek help. I mean, many people can go to elder people, but the last possibility is that they go to a psychologist to obtain services, as many of those who committed suicide can be diagnosed as Psychiatric patients after suicide, but not before. As a prevention of suicide, imagine that there is community awareness and awareness of psychological services in Palestine and asking for help from clinics and institutions that provide assistance in institutions located in cities" (Participant 7). 4.3 Summary This chapter presents the results of qualitative thematic analysis of 16 interviews conducted with 16 mental health professionals on the topic of suicide in Palestine by demonstrating nine themes . Each theme in the results answering a question of the study. 37 Chapter Five Discussion and Recommendations 5.1 Discussion This research represented suicide from many concepts. The first one is the explanation of the causes of Suicide. Second, introduce an overview of strategies related to the treatment and prevention for this phenomenon from the perspective of Mental Health `workers. The suicide Causes In 1897, from a socio-cultural perspective, (Durkheim, 1897) writes a treatise about suicide. He explains suicide as a phenomenon that came from four main factors, sacrifice integration, desperation, and moral confusion. we can't dismiss these reasons, however, these reasons are not seen in the modern ages and do not contain the mental illness. Suicide has been medicalized; however cultural and societal aspects contribute to the rising of the suicide rates. This appears in the result of the exam of (LGBT) community for example. The percentage of those people is high and that may be because of the marginalization and hostility to them. When conducting the interviews, (Participant 1), who works in a mental health center said that one of the reasons that lead to suicide is depression, specifically severe depression. There are also economic reasons, including poverty and unemployment, in addition to social problems such as problems over inheritance, problems between brothers and divorce issues. (Participant 2) who is working in another mental health center, said that the reason for the suicide is that "Suicide includes many complex and interrelated causes and personal opinion, the primary factor the feeling of inferiority. There are also social reasons. The reasons for the increase in the suicide rate in Palestine As (Participant 16), a school counselor in the Qabatya Education Directorate said in an interview with him that the causes are multiple. It is economic reasons, psychological reasons, and maybe family reasons. In Palestine, there is no single reason. We cannot 38 limit suicide to one reason. If we come for economic reasons, poor condition and lack of income can lead to the thinking of committing suicide. The prevention and Treatment Suicidal behavior is prevalent and highly repeated. In this study, we examine some samples of people who think about suicide whether they are teenagers or adults. Generally speaking, we can divide the strategies of the prevention into two sides, “high- risk” and “population”. “High-risk” deals with the individuals at high risk. “Population” deals with the social and environmental factors. (Zalsman, et al., 2016) share an overview in both risk and population aspects in how to prevent suicide. They surmise that the practical ways to prevent suicide from population terms are, for example: preventing access to toxins, drugs, or even jumping sites. All these ways we can apply to the Palestinian society at any house, but the main factor here is the awareness of the individuals about how to act, deal and also feel to those around them, so as not to neglect them and take any of these risks leading to suicide. The limits and restrictions to go deeper in the term and meaning of suicide, also many cultural factors, and the restriction in the access to the treatment of the disorders make the process of prevention difficult. When asked about how to reduce the phenomenon of suicide, (Participant1) said, “Increasing social awareness about the danger of suicide by shedding light on it within the different groups of society”. Psychotherapy and pharmacology have also impacted the reduction of the suicide percentage. School educational programs have also a sufficient part in the process of the prevention of suicide. Notice that our Palestinian school always exploiting the guiding role in schools to provide sufficient awareness to the students about the phenomena related to or that lead to suicide. Prevention strategies dearth is not the only thing to blame. Medical practices are rare in Palestine, as the only medications used after suicide attempts are the clozapine of antipsychotic. 39 The interventions of Psychotherapeutic have been investigated, however, we have to notice that the strategies of treatment are considered secondary prevention strategies, and are designed to reduce suicidal ideation or behavior. Without access to the addressing care, any discussion in the prevention and treatment of suicide is incomplete. WHO statistics represent that in middle and low incomes countries there are fewer than 0.5 psychiatrists per 100,000 people. The risk of suicide is hard to evaluate mainly because of its sensitivity. Although the strategies for treatment do exist, its effectiveness should be evaluated, and programs aiming to enhance the role of parents’ care for children, in maintaining the children’s level of mental health should be considered and developed as the primary way in reducing suicide. 5.2 Conclusion According to the results, the study concluded the following: 1. Reasons for suicide in Palestine are external pressures which include (some political pressures, economic difficulties, social difficulties, lack of psycho- social support, emergent situations such as Corona pandemic, family difficulties, social pressures, electronic blackmail, bullying, stain and cultural pressures) and psychological and personal difficulties which include (Psychological and Personal Difficulties, Emotional pressure, Biological and health difficulties, Lack of awareness and personal culture, Psychological and mental disorders, and Addiction problems). 2. There were no differences between males and females. The themes explaining the differences are the following: external reasons and pressures which include (social reasons, economic reasons, stain among females, family pressures, nature of the Palestinian society, responsibilities, national and value reasons, differences in life nature reasons, differences in role playing reasons, differences in culture reasons, body violence against females, social up growing, electronic blackmail, drugs, electronic games) and personal reasons which include (personal reasons, emotional reasons, feeling of inferiority among males, Style of thinking, psychological problems, differences in suicide methods, imitation of other cases, failed relationships). 40 3. Factors related to Palestinian culture in reducing the phenomenon included (cultural factors, norms and customs, national culture, Strain , religion affects suicide theme, family solidarity and social relationships) and factors related to increasing the phenomenon included (Israeli occupation and political situations, economic factors, social factors, decline in family community protection, psychological stress, spread of pattern of consumer behavior, consumer culture, socialization, losing community trust, losing self- trust, psychological diseases, mismanagement by the responsible authorities of the methods of education, inadequate abilities for treatment, feeling lose and depression, feeling isolation, failed marriage and relationships, treating females and social pressures, narrow geographic size, allowed and forbidden culture, negative thinking and electronic blackmail). 4. The dangerous intention to suicide in Palestine include : evaluating personal factors which include (evaluating case feeling, ideas and abilities to suicide, evaluating case thinking towards life, evaluating case surrounding, evaluating case feelings of psychological pain, evaluating case feelings of hope, how dealing with stress, how cooping stress, evaluating psychological rigidity, evaluating psychological health and diseases history), evaluating suicide plan which include (evaluating history of suicide attempts, repetition of suicide attempts, evaluating the distance time between each attempt and evaluating the plan, preparation, time, place, method and tools for the suicide attempt), evaluating case needs which include (evaluating drug therapy due to psychological problems or protection net, evaluating case needs transferring to specialist and evaluating case needs special social support) and evaluating environmental and circumstances factors surrounding the patient which includes (communicating family to get more information, searching in general and family data to get more information, evaluating reasons for suicide attempt, evaluating the individual's special relations and evaluating the individual's stage ). 5. Transferring procedures for suicide cases are: determining specialist's task when transferring which includes (determining the competent authorities to be transferred, communicating with officials, institution and specialist and informing the cases' family) and determining procedures specialist's task before transferring which include (determining self- support recourses to help hem not thinking suicide, determining family role and providing treatment plan to change suicide idea). 41 6. Informing the patient and his family about challenges related to this action includes: (collecting data about the conditions of suicide attempt, informing and communicating the family or the other competent, cooperation with the case's family, d