M E D I S C H E O P VA N G A S I E L ZO E K E R S
Suicide prevention
in asylum seekers reception centres
Background and guidelines for MOA staff
Suicide prevention in a sylum seekers recep tion centres
Background information
Contents
In February 2008, approximately 21,000 asylum seekers were housed at the various
reception centres in the Netherlands. Health care services that are available for these
asylum seekers are very similar to the services available to all other residents of the
Introduction 3
Definitions
3
Suicide statistics 3
Suicide attempts 4
Factors that influence the suicidal process 6
Early recognition of warning signs 7
Netherlands. The Central Agency for the Reception of Asylum Seekers (Centraal Orgaan
opvang asielzoekers, COA) has contracted local Community Health Services (GGDs) and
a health care insurer to provide these services. The health care insurer, in turn, has
contracted health care providers, including general practitioners, pharmacists, dentists,
physiotherapists, obstetricians, hospitals, mental health care providers and home care
services.
Co mmunity Health Se r v ices fo r Asy lu m Se e ke rs : th e M OA
How to act if suicide is imminent or
The Community Health Services (GGDs) play an important part in the provision of health
after a suicide or attempted suicide
care for asylum seekers. One of the main responsibilities of the GGDs is the provision
of public health services such as health education, child health care, infectious disease
control, and hygiene and safety inspections. Separate foundations called Community
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Agreements with the Central Agency
for the Reception of Asylum Seekers
(COA) on policy and practice 13
Finally 15
Health Services for Asylum Seekers (Medische Opvang Asielzoekers, MOA) have been set
up to provide these services for asylum seekers. The MOA and the GGDs have the same
responsibilities for preventive care and the same public health care objectives. Their task
is to monitor, protect and promote public health. The GGDs’ work is for the entire Dutch
population, including specific target groups. MOA foundations focus only on asylum
seekers in reception centres. This is reflected in the care provided by the MOA and the
way the organisation works.
MOA : the path to cu rat ive care
The MOA is also the asylum seeker’s first point of contact for health issues. MOA practice
nurses refer asylum seekers with health problems to mainstream health care, provide
information and support with self care, or specific medical advice. If necessary, the MOA
coordinates the care given by different health care providers to an asylum seeker.
NB: The Dutch system of health care for asylum seekers is to be reorganised in 2009.
Suicide prevention in a sylum seekers recep tion centres
Case 1 A female asylum seeker applied for asylum six years ago. What she would
like to have is refugee status, a home and the opportunity to work. She has left a
child behind in her country of origin. She is experiencing problems in the relationship with her partner. While waiting to see the MOA practice nurse, she tries to
slash her wrists with a razor blade.
Introduction
Suicide statistics
During their work at a reception centre for asylum seekers, MOA staff may be confronted
Approximately 1,500 people commit suicide each year
with suicide, suicide attempts and suicide threats. This publication gives some information
in the Netherlands. Suicide takes almost twice as many
about suicide and suicide attempts among asylum seekers. It also tells you how to recognise
human lives as fatal traffic accidents. MOA registration
the warning signs or problems that may lead to suicide and the action you should then take.
of causes of death among asylum seekers in the
Netherlands shows that 20 asylum seekers committed
suicide in 1998-1999. In the periode 2002-2003 there
Definitions
were 19 suicides and in 2004-2005 six people took their
Suicide
lives. This gives a gross mortality rate of, respectively, 1.4
An act with a fatal outcome which the deceased, knowing or expecting a potentially fatal
and 0.7 per 10,000 asylum seekers in reception centres
outcome, had initiated and carried out with the purpose of bringing about wanted changes
during those periods.
(De Leo D, Burgis S, Bertolote JM, Kerkhof AJM, Bille-Brahe U. Definitions of suicidal
behaviour: lessons learned from the WHO/EURO multicentre study. Crisis 2006; 27: 4-15.)
When compared to suicides among the general Dutch
population in 1998-1999 and 2002-2003, suicide among
Suicide attempt (al so calle d ‘ paras u icide’ )
A non-habitual act with non-fatal outcome that the individual, expecting to, or taking the
risk to, die or to inflict bodily harm, initiated and carried out with the purpose of bringing
about wanted changes.
(De Leo D, Burgis S, Bertolote JM, Kerkhof AJM, Bille-Brahe U. Definitions of suicidal
behaviour: lessons learned from the WHO/EURO multicentre study. Crisis 2006; 27: 4-15.)
asylum seekers occurred, relatively, twice to three times as
much. In the period 2004-2005, the suicide rate among
asylum seekers was no different to the rest of the
population of the Netherlands. Forty-one of the 45
suicides among asylum seekers in the three periodes
registered by the MOA involved males (89%).
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Suicide prevention in a sylum seekers recep tion centres
Suicide attempts
• Ag e
It is estimated that over 90,000 suicide attempts occur
In actual numbers, most suicide attempts are seen in the 30-39 age group; this applies
each year in the Netherlands, 30,000 of which are known
to both men and women. In all age groups, more women than men try to take their
about by care providers.
lives. There is a marked difference between men and women aged over 50. Suicide
The MOA has analysed data on suicide attempts among
attempts were reported among women over the age of 60, but not among men of the
asylum seekers in reception centres in 2002 and 2003.
same age. Incidentally, the youngest asylum seeker reported to have attempted suicide
During that period, MOA staff in five regions reported a
was 11 years old. The oldest was 64.
Incidence of suicide attempts in 2002 and 2003
total of 302 suicide attempts to their management. This
per 10,000 asylum seekers by age and gender (MOA reports)
shows that the number of suicide attempts among asylum
seekers is relatively twice as high as those among the
Other findings from the study:
• G en d er
In 2002-2003 there were about as many reports of
suicide attempts among male as among female asylum
seekers. During that time, 40% of the asylum seekers
in reception centres were women and 60% men.
So suicide attempts among female asylum seekers
occurred 1.5 times as much as among male asylum 50
Suicide attempts per 10,000 per year
Dutch population.
40
30
20
10
0
0-18
19-29
30-39
40-49
50-59
over 60
Age group (years)
seekers, relatively speaking, i.e. 26 and 18 attempts Men
respectively per 10,000 asylum seekers.
Women
• Cou nt r y of ori g i n
In 2002-2003, relatively the highest rate of attempted suicide was seen among Iranians
(64 per 10,000 asylum seekers from Iran), followed by people from countries of the
former Soviet Union and the Middle East (40 and 30 per 10,000 respectively).
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Suicide prevention in a sylum seekers recep tion centres
• Rea sons
Suicide is a process
In cases where the MOA worker knows why suicide
When someone attempts suicide, it is almost always the end of a process of many years:
was attempted, about 35% mention the asylum
vague thoughts become increasingly concrete and compelling, the person then starts to
application (sometimes combined with social concerns make plans and say their goodbyes before the actual attempt to take their life. It is often
or mental health problems). In 17%, there was a mental (but not always) a long and agonising path to suicide or attempted suicide.
illness, 13% were directly caused by social concerns, and 12% by transfer to another location. In one in six asylum seekers, the MOA worker did not know what had led to the suicide attempt.
• Method s used
More than half of the suicide attempts reported (61%)
involve pills and/or alcohol. In 17%, the person used a
knife or other sharp object.
• Menta l health care
Approximately half of the asylum seekers were known
to have been undergoing mental health treatment
when they attempted suicide. This percentage is
comparable to that of the general Dutch population.
• H ospital treatment
Over 70% of the asylum seekers who attempted
suicide needed hospital treatment.
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Suicide prevention in a sylum seekers recep tion centres
Factors that influence the suicidal
process
There are several factors that may increase the risk of
suicide or attempted suicide, while others can have a
preventive effect. These factors apply to the risk of suicide
and suicide attempts in general, but are described more
specifically for asylum seekers where relevant.
Risk factors
-painful experiences that could ‘provoke’ the person’s actions;
Psychiatric problems. Some asylum seekers are already
suffering from psychiatric disorders when they arrive in
sexual abuse, exclusion
the Netherlands.
•
tension within their family or at the reception centre, problems at school
•
the authorities’ decision to transfer or deport them, an unsuccessful asylum
Mental health problems, for example poor problemsolving skills or feelings of helplessness.
Drug or alcohol abuse, or inappropriate use of
medication.
Traumatic experiences in combination with other factors.
In the case of asylum seekers, this could relate to:
-events that took place in their country of origin or
during their flight;
-the way they are living at the reception centre,
particularly in combination with psychiatric problems
•
application
- suicides and suicide attempts in their environment;
•being
confronted with suicide in their immediate environment weakens the psy-
chological barrier to committing or attempting suicide, especially if they
themselves are having psychosocial problems
Previous suicide attempts:
•
40% make another attempt (the exact percentage for asylum seekers is
unknown)
Certain social-demographic characteristics (in combination with other risk factors):
•male
(depression and/or a post-traumatic stress disorder);
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loss of loved ones and possessions, losing money, (MOA registrations: 93% of suicides among asylum seekers concern men, as
opposed to attempted suicides, which occur more among women)
•
single
•
asylum seekers from the Middle East and the former Soviet Union
Suicide prevention in a sylum seekers recep tion centres
Case 2 A woman who suffers from severe headaches asked a friend to give her sleeping pills. She took them, together with 13 other pills.
In her country of origin she had been the victim of rape and violence. Then two years ago her husband died in the Netherlands in a traffic
accident. Much of her grief has been expressed by self-harm. She has been very distressed and living under a lot of strain the past few years.
She feels so alone and finds having to do everything by herself very difficult.
Prevent ive fac tors
Early recognition of warning signs
Examples of preventive factors that may reduce the risk of
Approximately three-quarters of the people who commit suicide have made their plans
suicide are:
known weeks beforehand through all kinds of verbal and non-verbal communication.
- good relationships with family and friends,
Recognising these warning signs and finding a way to discuss them is very important if
- having an aim in life,
people who are suicidal are to be prevented from actually taking their lives. Reacting in
- wanting to get help,
the appropriate way can have an effect on the suicidal process.
- knowing where to get help,
- being given and taking the opportunity to discuss feelings and thoughts with others,
- trusting a care provider,
- taking comfort from religion.
Ve r ba l wa rn i n g s i g n s
- “I don’t want to go on like this”
- “I’m useless”
- “I’d like to go to sleep and never wake up again”
- “they’re all better off without me”
- “life isn’t worth living any more”
- “I don’t care what happens to me”
- …
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Suicide prevention in a sylum seekers recep tion centres
Behav ioural warni ng s ign s
-downcast, pessimistic,
- worrying, not sleeping,
- frightened, despairing (about the future),
- unable to think properly or remember things, confused,
- feeling increasingly helpless and hopeless,
- becoming withdrawn, spending time alone,
- abuse of alcohol, drugs, medication,
- sudden fits of crying or anger,
- losing interest in things they usually like doing,
- not looking after themselves or their clothes,
- becoming interested in things to do with death,
- writing a will or a suicide letter,
- giving away personal belongings,
- … .
Ca n suic i d e b e p red icte d?
There is an increasing risk of suicide when several
warning signs are seen during a long period and against
a background of the previously mentioned risk factors.
But sometimes there aren’t any obvious signs. So suicidal
behaviour cannot always be predicted. Warning signs are
often only recognised with hindsight, leading to much
uncertainty about the reasons for the suicide, and leaving
family and friends – and also care providers – feeling guilty
(“if only I’d …”).
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Case 3 A 19-year-old girl took an overdose of pills and alcohol at an asylum
seekers reception centre. Her GP was called and the girl was taken to hospital,
where her stomach was pumped. A crisis service and mental health care team
were contacted, and they arranged immediate outpatient treatment as well
as an appointment to discuss admission to a psychiatric hospital. Three months
before, she had also attempted to take her life.
Suicide prevention in a sylum seekers recep tion centres
How to act if suicide is imminent or after
a suicide or attempted suicide
Befo re a sui c i d e or sui cide atte m pt
If a care provider suspects or has received reports that
someone at an asylum seekers reception centre is planning
to take their life, then it is his or her responsibility to take
the appropriate action. Staff who are neither doctor nor
nurse should immediately contact a MOA nurse or doctor.
MOA staff themselves cannot assess the risk of an asylum
seeker committing suicide; mental health expertise is
called for. If the doctor or nurse thinks the case is urgent,
he or she will consult the person’s GP to arrange a referral
to a mental health crisis service (following MOA protocol).
Af te r a s u i c i d e o r a tte m pte d s u i c i d e
If someone has actually committed or attempted suicide, then the doctor or nurse should
get in touch with the person’s GP or an emergency service. The incident should also be
reported to regional management (following MOA protocol). This notification is used to
collect national data which can help shape national policy.
The MOA should always take risk factors into account
Su i c i d e a s a m ea n s of g a i n i n g cont rol
and watch out for warning signs. Warning signs need to
Sometimes it is thought that a threat to commit suicide is a way to try to gain control of
be taken seriously and discussed with the asylum seeker
a situation (a way of resisting deportation, for example). Only an expert care provider can
concerned, before putting them in touch with a mental
assess how serious a suicidal warning sign is. MOA staff must take warning signs seriously
health care professional. The best way to do this is to
and contact a doctor or mental health care professional, even if the threat seems to be
simply ask the person a direct question, for example:
manipulative. For there is always a risk that the person will actually attempt suicide.
“do you ever think about taking your life?”
You can have a positive effect on the suicidal process by
reacting adequately to warning signs, talking about them,
and involving the person’s GP and/or a mental health care
professional. Always get in touch with a youth health care
worker if the person is very young.
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Suicide prevention in a sylum seekers recep tion centres
Taking action
- Listen and react sympathetically. Active listening and showing your sympathy will make
the person feel less rejected or misunderstood.
Talking
- Try to structure the person’s problems and feelings by saying, for example, “Am I right
A first step to suicide prevention is getting the person to
in thinking that…”, This helps to reduce anxiety and confusion, making the problems
talk about their thoughts on suicide. Some people don’t
easier to discuss and handle. Decide whether using publications for asylum seekers
think they are capable of talking to someone who is
about mental health problems and about mental health care may be useful.
suicidal. If that applies to you, don’t hesitate to ask a
colleague to talk to the person concerned.
- Consult other care providers and make sure the asylum seeker sees their GP or mental
health care provider. Make appointments for the asylum seeker to consult and get support from others in the care network if it is difficult to persuade the person themselves
D os
-Talk calmly and openly about death and wanting to die.
People who want to die often find it very difficult to
to seek professional help. In this case, share the responsibility with others, so that the
asylum seeker is given the best possible care.
- Keep an eye on other members of the family as the person’s state of mind may affect
talk about their feelings. Simply the fact that someone
them too, especially if children are involved. If you think that children may be at risk,
is asking them what’s on their mind may help them to
get in touch with the youth health care service.
overcome their inhibitions. They are relieved because
it makes them feel less isolated at last. Encourage the
D on’ts
person to talk about suicide.
You may mean well, but doing anything described below is more than likely to have a
- You may well feel powerless and have questions of
negative effect. So definitely don’t:
your own, so make sure that you too have someone to
- disapprove of the person or their behaviour;
talk to. Ask your management what possibilities there
- play down the person’s problems;
are for supervision or other forms of support.
- come up with all kinds of solutions;
- Always take someone’s wish to die seriously and make
- give the person a lecture;
that obvious. Try to understand the situation and ac-
- raise the person’s hopes;
cept the fact that there are problems.
- promise the person that you won’t talk to anybody about it.
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Suicide prevention in a sylum seekers recep tion centres
Referral and collaboration
For referrals to social workers, mental health care and social services for children and
young people: see the MOA protocols. These are general MOA guidelines for clarifying
problems and referral to the appropriate care providers.
In April 2006, GGD Nederland published ‘A methodology for drawing up multi-agency
guidelines for asylum seeker health care in the Netherlands’. This booklet contains MOA
guidelines for collaborating on a local level with several partners in the care pathway (e.g.
In a crisis
social workers, mental health care, GPs) and other organisations such as the COA. Ask
If someone is experiencing an acute suicidal crisis, you
your regional management whether such agreements have already been drawn up for
must take immediate action. That means being pro-
suicides in your area. If so, make sure you are aware of them. If you discover that there
active and getting others involved.
are no agreements or the agreements are insufficient, tell your management about the
-Prevent them from taking a definite decision about
booklet mentioned above. An example of local collaboration is MOA East Netherlands’
suicide and try to buy time.
Local Guidelines on Attempted Suicide.
- Remove anything that could be lethal, such as pills,
weapons, etc, if necessary with the help of others
Aftercare (postvention)
(family or friends). Arrange for a weapon to be
A suicide in the asylum seekers centre, or someone’s threat or attempt to take their life,
handed in to the police.
always has a great impact on yourself, the other residents and staff working in all parts
- Try to relieve any social isolation. Make sure the
of the centre. It is usually a very traumatic experience, leaving people with questions and
suicidal person is not left on their own “in this feelings of guilt.
state”.
- Do your best to involve people in the person’s
Ask your management about the aftercare that is available for you. Also ask them about
immediate surroundings. Plenty of support from
the tasks and responsibilities of the MOA and its partners (i.e. mental health care, social
people around them can reduce stress and make
work, other emergency services) for the aftercare of residents and staff. Ask them to
everything more bearable.
make sure that everyone knows about who should be doing what for the asylum seeker
- Make sure that a crisis service is called in.
concerned and all the people in his or her immediate surroundings.
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Suicide prevention in a sylum seekers recep tion centres
Af tercare for an asy lu m se e ke r wh o h as
a ttempte d suic i d e
There is a MOA protocol regarding the coordination of
care by the practice nurse for an asylum seeker who has
been treated in hospital after a suicide attempt. It involves
reviewing the asylum seeker’s needs and referring him
or her to the appropriate care provider. In the section on
referral and collaboration, the protocol describes the need
for working guidelines for the care providers involved:
Af te rca re for M OA sta ff
a MOA doctor, the person’s GP, the practice nurse, the
Don’t hesitate to talk to colleagues and your MOA manager about your feelings and what
hospital and the mental health care service.
you have experienced. It’s important to realise that MOA staff themselves may need aftercare. The grieving process of a member of staff will depend upon how long and intense
During the period immediately after an attempt, there is
his or her relationship was with the deceased or the person who has attempted suicide.
a risk of it happening again, so the appropriate care does
It may involve anger, anxiety, guilt, and sometimes even relief, if the suicide was the
need to be available during that time.
end of a long and painful process. It may also make them doubt their own professional
Aftercare for reside nts a n d ot h e rs i n t h e
imm e d i ate surround in gs
Make sure you’re aware of the availability of aftercare
for residents and other people at the centre who
were involved in a traumatic incident such as a suicide,
attempted suicide or suicide threat. Ask your MOA
manager about this.
If anyone in the centre has had to deal with an asylum
seeker’s suicide, attempted suicide or suicide threat,
contact the person who coordinates aftercare and ask
him or her to take the appropriate action.
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competence. A suicide or suicide attempt may make them feel like they’ve failed – which
is not usually the case. Ask your MOA manager about organisational policy on traumatic
experiences at work.
It’s important that colleagues and management give continuing support to those involved.
Their attention, concern and interest after the incident are of vital importance to the
recovery process. Reviewing cases of suicide and attempted suicide is a way to find out
whether new measures need to be taken. These could be measures to prevent suicides
among asylum seekers, but could also involve training professionals to act on warning
signs.
Always report suicides, attempted suicides and suicide threats to your MOA manager,
using the agreed procedure which is part of your centre’s personnel policy, so that he or
she can arrange aftercare for the staff concerned.
Suicide prevention in a sylum seekers recep tion centres
Agreements with the Central Agency for the Reception of
Asylum Seekers (COA) on policy and practice
You and your MOA manager will need to agree on working practices with the COA at
your reception centre. Come to an agreement about the asylum seekers who the MOA
consider to be at risk – taking confidentiality into account – and put them in writing, after
a multi-agency discussion for example. Include agreements such as those regarding the
MOA being informed at an early stage about decisions that have far-reaching implications
(i.e. transfer or deportation) for people who are considered to be at risk of attempting
Repo r tin g to MOA manage m e nt
suicide. This is important for two reasons: the people concerned can be carefully
A suicide, attempted suicide or suicide threat must be
monitored and detailed medical records can be prepared in time. If at-risk people are
reported not only to your manager with regard to after-
to be deported, ask the COA to talk to the immigration and naturalisation service (IND)
care for staff, but also to regional management, following
about consulting their medical advisers regarding the measures that will need to be taken.
MOA protocol. The reasons for this are to gain epidemiological insights at a regional and national level, to improve
Come to an agreement with the COA on how their staff should communicate with the
the quality of MOA services, and to draw attention to the
MOA if they are worried about certain asylum seekers, or if they have heard explicitly from
need for health promotion among asylum seekers. The
an asylum seeker that he or she can’t cope with life any more.
protocol and reporting forms are available on the GGD
intranet.
Certain incidents, such as suicides reported at reception centres, may be interesting stories
for local and national media. And incidents like these may also be used by campaigners
to express their dissatisfaction with, for example, asylum seeker policy. Refer journalists or
campaigners to your management. Don’t talk to them yourself.
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Suicide prevention in a sylum seekers recep tion centres
An important part of suicide prevention is recognising the warning signs that may lead to suicide or attempted suicide and responding
adequately to them. This publication gives advice on how to act. But a booklet alone cannot teach you all you need to know. Ask your MOA
manager about the availability of courses or any other training in preventing suicide among asylum seekers. Intervision and other peer
group support also has a vital part to play in professional practice.
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Suicide prevention in a sylum seekers recep tion centres
Finally
Doctors and nurses should always act according to Dutch medical association
guidelines and MOA guidelines for confidentiality.
This leaflet ‘Suicide prevention in asylum seekers reception centres’ is a translation of
the Dutch brochure ‘Suicidepreventie in AZC’s’, published in 2007 by the department of Community Health Services for Asylum Seekers, Netherlands Association
for Community Health Services (Landelijk Service Bureau MOA, GGD Nederland) in
cooperation with several experts and organisations in the field of suicide prevention.
Both the Dutch and English version are available on the internet:
www.ggdkennisnet.nl/44795.
GGD Nederland
P.O. Box 85300
3508 AH Utrecht
The Netherlands
www.ggd.nl
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