As recent suicide statistics reveal, suicide can affect people of all demographics (da Silva, et al, 2019). In the United States, rates of suicide have jumped almost 30% within the years of 1999 and 2016, with the largest increase noted in both adolescents and older adults. Internationally, suicide continues to be one of the leading causes of mortality. Although it is unclear as to why suicide rates seem to be increasing across the globe, proposed reasons include economic instability and the opioid crisis (Fornili, 2018). Therefore, it becomes critical to educate and provide interventions to people contemplating suicide to prevent the increase in completed suicides. Tools such as the 7-Step Integrative Healing Model (Kalayjian, 2002 & 2010; Kalayjian & Diakonova-Curtis, 2018), National Institute of Mental Health (NIMH) action steps and telephone lifelines can provide interventions as well as education on emotional management and psychological care. In this paper we present a case study of a suicide prevention lifeline in Armenia, with emphasis on grassroots partnerships between MeaningfulWorld and the local communities.

Suicide continues to be one of the leading causes of mortality worldwide (McLoughlin, et al, 2014). Suicidal behavior includes suicidal ideations, plans, or attempts, which can all contribute to risk for complications and subsequent attempts (Stein et al, 2010). It has become a major public health concern for adolescents, with it being the second leading cause of mortality in the U.S. for teenagers between 15 and 19 years of age (Ahmed et al., 2017). Across New Zealand, Australia, and Canada, a similar pattern of high suicidality among indigenous youth is evident among teenage populations (McLoughlin et al., 2015). Risk factors for suicide in both developed and developing countries include female sex, younger age, lower education level, lower income, unmarried status, unemployment, adverse childhood experiences, parental psychopathology, and presence of mental health disorders (Borges et al, 2010).  The World Health Organization recognizes suicide as a critical public health issue globally, with the goal to develop national suicide prevention strategies including lifelines (Naghavi, 2019).  Those suffering from depression, post-traumatic stress disorder, and other co-morbid health conditions are at risk for poorer outcomes and are at higher risk for suicide (Collins et at, 2013).

Female teenagers are more likely than their male counterparts to experience suicidal ideation and attempts, yet boys commit suicide more frequently than girls (McLoughlin et al., 2015). Globally, over twice as many boys between 15- and 19-years old completed suicide, with a rate of 10.5 per 100,000 persons (McLoughlin et al., 2015). The greater frequency of completed suicides among boys has been attributed to greater risk-taking behaviors (McLoughlin et al., 2015). However, in countries such as China and India, there are higher rates of suicide among teenaged girls (McLoughlin et al., 2015). These rates may be due to more pronounced gender conflicts that are present in traditional agricultural societies (McLoughlin et al., 2015).

The lack of data on suicide rates in developing countries, along with the inconsistencies in completed suicide reporting worldwide, creates a gap in the knowledge concerning the true extent of suicide mortality in developing countries. Many studies on suicidal ideation and attempts derive their data from the World Health Organization (WHO) regions, yet the WHO has almost no data from certain African regions as well as several South-East Asian, Mediterranean and Latin American countries and regions (Bertolote & Fleischmann, 2002). As such, the data derived from WHO may differ from real figures of suicide.

In Armenia, the rate of suicide per 100,000 population was reported to be as 5.7 in 2016, with the rate found to be increasingly high in men (GHO, 2018). The rate of suicide attempts in adolescents is particularly concerning, with 15- to 16-year-old students indicating a lifetime rate of 4.1% in a study where the median lifetime rate was 10.5% (Kokkevi, et al, 2012). Armenian students also ranked high when reporting self-harming thoughts in addition to having attempted suicide (Kokkevi et al., 2012). The need for suicide prevention and intervention becomes even greater when looking at gender differences in suicide attempts. There is an increased risk for suicide attempts among female adolescents compared to males in several countries, however, this risk is particularly high in Armenia (Kokkevi et al., 2012).

Reasons for Increases in Suicide Rates in Armenia

In Armenia, myriad factors have led to increase in suicide rates, including poverty as a result of collapsed Soviet system, establishment of an independent Armenia, the war with neighboring Azerbaijan (due to territorial conflict re Artsakh, or Nagorno-Karapagh), economic instability, being land locked (as both Azerbaijan and Turkey have blocked their borders with Armenia), multiple refugees from Iraq, Syria, and Artsakh wars, and the coronavirus pandemic. As compared to other countries in Europe, Armenia accepted more refugees from Syria than any other country.

After the collapse of the Soviet Union, upon Armenia establishing independence in 1991, disruption of trade and economic changes led to a socioeconomic crisis that has continued to affect the country, with over half the country living in poverty (Sargsyan, et al, 2016). Additionally, ongoing attacks from the neighboring countries of Azerbaijan and Turkey have led to declining mental health and increase of PTSD (Sargsyan, et al, 2016).  Not to mention the long term-generational trauma of the Ottoman Turkish Genocide of the Armenians, with its denial campaign by the Turkish government, and the latest war in 2020 September exacerbating the generational trauma. Social determinants of health affecting suicide rates also include family culture, life satisfaction, access to specialized health care services including mental health, sociopolitical climate, and societal/cultural factors.

Grassroots Partnerships

On 1 January 2016, the United Nations Summit presented the 17 Sustainable Development Goals (SDGs) of the 2030 agenda for Sustainable Development.  These 17 goals are the blueprint to address global challenges including inequality, health and wellness, education, peace, and justice. SDG goal #17 ‘Revitalizing Global Partnerships for Sustainable Development’ provides a definition for Grassroots collaborations.  The SDG defines Grassroots collaborations as collaborations in which organizations work with local community members such as families, teachers, spiritual leaders, non-profit organizations, policy makers, law enforcement, health care professionals, and other community members to affect positive change.

In the spirit of grassroots partnerships and collaborations, ATOP MeaningfulWorld has partnered with community organizations to support mental health around the world in 48 countries and 26 states in U.S.A. We used a three-tiered approach of 1. healing and education, 2. research, publications, and outreach, and 3. policy revisions and advocacy in collaboration with the local communities.  One example of this is our work with local organizations in Armenia to develop a suicide prevention lifeline. Below we discuss the steps taken to accomplish this, lessons learned, and future actions for the lifeline.

Education

When dealing with the thoughts of suicide, an essential tool used for intervention is the 7-Step Integrative Healing Model (Kalayjian, 2002, 2010, 2018), adapted for all age groups. This is a biopsychosocial and eco-spiritual model that utilizes seven-steps in which various aspects of feelings are assessed, identified, explored, expressed, processed, validated, and finally re-integrated. It is an integrative approach, as it incorporates multifarious proven psychological modalities from psychodynamic, interpersonal, existential, humanistic, learning-theory, energy theory, electromagnetic field balancing, to mind-body-eco-spirit practices. The success of this model is its focus on emotional management, nurtures emotional intelligence, and its nurturance of ecological consciousness. Another strength is its focus on meaning-making, mindfulness, and forgiveness. The 7-Step Integrative Healing Model (Kalayjian, 2002, and 2018) was created to address the needs of the humanitarian relief missions, to address the collective traumas faced around the globe, and to establish self-care. This healing model has been implemented to help support trauma healing and decrease suicide rates in 48 countries including: Armenia, Haiti, Palestine, and Nigeria and has been shown to be culturally sensitive and is based on theoretical framework (Mura & Kalayjian, 2019; Toussaint et al, 2017; Adeyanju et al, 2015; Kalayjian & Simmons, 2016).

The Intervention begins with Step 1, where levels of traumatic stress symptomatology are assessed through valid and reliable psychological assessment questionnaires measuring the severity of the trauma, followed by Step 2, where the individual is encouraged to identify and express one’s feelings using a user-friendly “Emotional Management” handout. This is supported by the psychodynamic theory (Freud. 1910). Subsequently, Step 3, involves receiving empathy and validation for the feelings that were expressed. Based on Sullivan’s Interpersonal Theory (1953), this validation is essential for trauma healing and closure. This helps one feel acknowledged, understood, heard, and supported, and greatly alleviates one’s levels of anxiety and distress.

Next, Step 4, encourages the discovery of meaning in the expressed experience or situation that the individual is going through. This step is based on Frankl’s logotherapeutic principles (1962). For example, one is asked to think about the lessons that can be learned from the situation/experience. This in turn helps one find value and meaning in the experience, giving the individual the strength to move forward, using the trauma as a stepping stone. Then, Step 5 involves the provision of helpful and didactic information such as practical tools and resources, which are shared to help in the now and the future. Steps 6 and 7 are the final two steps that incorporate the eco-spirit levels of healing. Step 6 encourages one’s connection with the Mother Earth, helping understand the value of one’s environment towards self-healing, and finally Step 7 ends with a holistic based breathing and yoga-based exercise routine known as “Soul-Surfing,” that aids the individual connect with one’s mind and body, as well as feel more grounded, relaxed, and centered. In summary, all seven steps work together to provide the individual with the support and tools to manage emotions in a way that help reduce levels of suicidal thoughts, by empowering the person to reframe the calamity and distress as a stepping stone, and celebrate the new lessons-learned.

In addition to the intervention techniques such as the 7-Step Integrative Healing Model (Kalayjian, 2018), our Humanitarian Teams have worked in Armenia to launch a suicide prevention lifeline. The larger project’s mission is to create a public service that offers those in need of a psychological guidance a direct toll-free telephone lifeline that offers guidance in coordination with local law enforcement and mental health providers. The lifeline would aid preventing loss of life and instill hope by teaching emotional management by increasing the availability of Armenia’s psychological health care.

As discussed, since 2003, suicide rates in Armenia have increased by more than 100% and there has been a significant increase in teenage and older adult suicide (WHO, 2018). Armenia has the third highest rate of suicide in the previously Soviet Republic, while the Kievyan Bridge in Yerevan is now called “Suicide Bridge” due to the frequent number of suicides (Kalayjian, 2017). A toll-free lifeline providing free and anonymous support becomes a necessity to provide a 24-hour service for crisis management and suicide prevention support. This project would aid in increasing the availability of psychological health care for Armenians, as well as providing follow-up mental health and psychological first-aid, crisis management, and long-term care if needed. The following objectives of the project are identified: a) to reduce the risk of suicidal behavior and prevent loss of life among young and older age groups in Armenia; b) to provide a 24/7 service of staff trained by local and international psychologists that are skilled in crisis management and suicide prevention; c) to provide intensive training to volunteers who will service the lifeline; d) to work in collaboration with law enforcement officials and local psychological health centers if immediate intervention or additional care is warranted; d) to provide crisis management, follow up mental health and psychological care.

Outreach and pre assessment of needs

We sent promotional flyers to affiliated institutions, who utilized their social media accounts and websites to advertise the lifeline. ATOP staff contacted organizations through email and were followed up with phone calls (via apps such as WhatsApp and Viber), and through direct phone calls. Moreover, our team sent letters to stakeholders including government agencies and departments, local NGO’s and civil society groups and religious groups, police and armed forced/military, orphanages, women’s human rights centers, and men’s groups. In the letters we communicated our intention to establish a lifeline in Armenia, while seeking their input and support. We asked for their input in terms of ways to adapt our educational workshops and programming to the needs of their communities, and to identify volunteers to be trained by our team. Additionally, we included members of the public in our efforts to generate awareness on mental health and suicide prevention through discussions in the public sphere in malls, large public gatherings, and the radio and newspapers as well as through flyers and banners.

As a first step, our team aimed at getting familiarized with the community. To achieve this, we resorted to our allied organizations. MeaningfulWorld has related to Armenian governments, NGOs, universities, orphanages, medical institutions, United Nations offices in Armenia, and religious organizations for over thirty years, since our first humanitarian mission to Armenia in February 1989 to aid in the aftermath of the devastating earthquake of December 1988. These organizations helped us identify the needs of the communities, understand previous efforts led by other organizations, determine needs of different sectors as explained by local professionals so we could prevent unnecessary duplication of efforts.

As a second step, we aimed at identifying the need for a suicide prevention lifeline, with the collaboration of stakeholders from government, religious, academic, and community-based organizations.

In our pre-assessment, we identified that suicide was considered taboo in Armenian society, despite being a prevalent issue nationwide. It is estimated that the number of people in the population who seek psychological services in Armenia is less than one percent (Gasparyan, 2020). As such, one of the main goals that resulted from the assessment was to work on tackling the stigma that existed around suicide which had been identified as an obstacle for starting discussions around mental health and suicide prevention.

Our team started preparing for this mission in April 2019, six months before traveling to Armenia in October 2019. Our team consisted of 3 people, two psychologists (one with Ed.D., and the other Psy.D., and third with a B.A. in psychology). To start conversations around suicide, we first distributed flyers advertising the suicide prevention lifeline which our stakeholders disseminated through their websites, social media and email accounts. We were guest lecturers at the International Conference celebrating 100th anniversary of Yerevan State University: the 7th International Conference on the Current Issues in Theoretical and Applied Psychology. In collaboration with our stakeholders, we identified a total of 65 volunteers to operate the phone line. These volunteers came from affiliated universities and local hospitals. MeaningfulWorld staff trained the volunteers responding to emergency phone calls, referral and follow up. To help organizations build a strong support network, our staff compiled a resource list that would be used to refer callers to follow-up care when needed.

As expected, our team encountered resistance, as there still exists, a pervasive stigma of ‘shame ‘(amot in Armenian) against suicide and psychiatric mental health needs. Local community organizations were open about the needs of their communities, but discussion around suicide were viewed as shameful or inappropriate.

To challenge this stigma, MeaningfulWorld met with local leaders and created educational workshops for volunteers with the goals of breaking down different topics related to suicide awareness, intervention, and prevention, as well as trauma healing, transforming generational trauma, nurturing Emotional Intelligence, and transforming Horizontal Violence. We held meetings with community leaders to discuss challenges around talking about suicide, and identify ways that community leaders believed suicide could be destigmatized. After these initial discussions, our team began suicide awareness and prevention campaigns via radio and billboard advertisements. This indicates an effort not only to prevent suicide through a lifeline, but also through programs designed to address the social perception of suicide and the importance for reaching out to ask for help.

One example of this campaign is the transforming Horizontal Violence, using banners indicating: Don’t be like a crab in the bucket, pulling one another down; be a true human by pulling one another up; another campaign addressed ecological consciousness with this message:  Armenia is my home!

Initiation of the Lifeline          

The opening ceremony for the lifeline occurred on World Mental Health Day, 10 October 2019 at the Yerevan State University. Multi stakeholders were present, representing government, academia, orphanages, NGO’s, university students, administration, priests, and civil society. The humanitarian relief mission directly reached 575 people and indirectly reached over 2,000 people. With the additional radio and social media posts, we reached over 50 thousand people. Additionally, Meaningfulworld staff conducted 19 training workshops in three different cities in Armenia; Yerevan, Gyumri, and Vanadzor.  As of September 2020, the COVID-19 pandemic has forced the center to work remotely. Although the physical center was scheduled to open in April 2020 but is necessarily delayed due to the global pandemic, our teams continue working with the volunteers through zoom meetings.

Lessons learned

The burden of suicide mortality is a health crisis that is evident not only in the United States, but also globally. While suicide rates in the United States of America may be sparked through high-profile cases of celebrity suicides, the worldwide rates of suicide indicate that individuals of all ages and backgrounds can be affected. Suicide is a growing concern in adolescent- and older individuals in the Republic of Armenia. Political turmoil, economic instability, territorial and religious conflicts with neighboring Muslim countries of Azerbaijan and Turkey, independence from Soviet regime in 1992, as well as natural disasters, are some of the causes that may contribute to growing rates of suicide.

With increasing rates of suicide globally, prevention and intervention efforts need to be just as widespread and effective to be applied cross-culturally. The 7-Step Integrative Healing Model is one such intervention effort as it has been adapted for all age groups and cultures. Its utilization of psychodynamic, interpersonal, humanistic, energetic, electromagnetic, mindfulness meditation and learning theory makes it so that it can be applicable across populations. The model begins by assessing the psychological health of the individual, before moving on to discovery of meaning in one’s situation, providing tools for catharsis, discharge, empathy, validation, healing, recovery, and providing connections with one’s surroundings and their social network, in order to aid healing. The 7-Step model can serve as a tool for coping and provide individuals with techniques to find meaning in their lives even in the direst situations (Frankl, 1962).

Additionally, we learned the following lessons through our grassroot collaborative efforts. Grassroot organizations comprise of members of the community, therefore, most of them are also suffering from the impacts of traumas and need emotional support. Members of grassroot organizations are overwhelmed, due to the collective, individual, vicarious, and horizontal violence and are needing of resources and relief. Members of grassroot community need the skills to organize and prioritize, as well as deliver the tasks as established. We have learned that we could be instrumental to introduce grassroot organizations to support one another in times of distress. Our assessment revealed that most were not aware of one another’s existence (fragmentation due to Horizontal Violence). We have learned that change is met with resistance in every country, especially by government officials, which challenge us to be persistent, and not take ‘no’ responses personally and continue to persist to meet the needs of the community. We learned the importance of continued and consistent support on our part, as psychology is a rather new area of specialty, and often grassroot leaders wait for us to initiate activities, programs, and conferences. We learned the importance of nurturing volunteerism and service to humanity. This is another underdeveloped area in Armenia; servicing, uplifting, and empower their community at large without receiving monitory payments. We learned the importance of helping grassroot organizations to list their resources, and how to outreach and fulfill inadequacies, and fully utilize resources available, including the human spirit. We learned the importance of our Motto: When one helps another, both become stronger. As we returned with a renewed resilience, appreciation of all the privileges we enjoy, and discovered a new meaning in our lives.

Continuation of efforts

To ensure continuation of our efforts, collaborating Universities agreed to maintain trainings around suicide prevention, this will help tackle the stigma surrounding suicide and would serve as a reminder of the resources available, including the lifeline.

Additionally, the lifeline will be managed by the Stress Center, the Yerevan State University, and the psychology volunteers we recruited and trained. As a result of the COVID 19 pandemic, the lifeline will be 100% remote and volunteers will be working remotely. Currently, private donors are supporting the lifeline until a grant is written to fund this program.

Suicide has become a public health crisis globally, as well as in the Republic of Armenia. Other factors include the recent Coronavirus pandemic and the war waged by neighboring Azerbaijan and Turkey over Artsakh, Armenia. Therefore, it is critical to tailor interventions to address the growing mortality in adolescents as well as middle-aged and older individuals in Armenia. Through multilevel collaborations with multi stake holders, we established the first suicide prevention lifeline in Armenia using grassroot partnerships with local community leaders, government, police and justice system, health care providers, teachers, religious figures, public officials, and nonprofit organizations including orphanages, domestic abuse shelters, and human rights organizations. This is in line with the United Nations SDG #17 of partnerships. This grassroot collaborations addressed inequalities and improved access to needed mental health care services. After developing a need, local mental health providers were trained to be able to respond to suicide prevention lifeline services, which is critical in helping the mental health of the local populations.  ATOP Meaningfulworld was able to work collaboratively to address mental health disparities and work towards preventing suicide. Our team returned with renewed hope, gained strength in resilience, learned to appreciate our privileges and the value of sharing our resources with the Republic of Armenia.

Recommendations

Future research should explore the impact of grass root collaborations on the mental health of the Armenian people in general, and the impact of grass root leadership and suicide prevention lifeline in particular.

We recommend a network of grassroot organizations, continuing to work collaboratively after our humanitarian teams have left Armenia. We recommend continued assessment at 6-month intervals, to elicit the impact and the effectiveness of the lifeline, and to evaluate and update as needed. A group database for all the volunteers will be used to enhance communication, organization, evaluation, remodification, and resource building.

Conflict of interest

The authors declare they have no known competing financial interests that might influence the work reported in this paper.