Lessons from TELL

Noon in Tokyo's vibrant Chiyoda district, on one of the hottest days of summer. Fifty people are carrying bags, handing out resources, and talking to complete strangers. They are sweaty, but they are smiling. These people, volunteers and corporate sponsors, are talking with precision and passion about one of Japan's silent crises: suicide. As an enthusiastic intern carrying a box of cotton tote bags through the busy Tokyo metro that morning, I had no idea how much I would learn about effective advocacy.

Suicide is a global issue, but it is difficult to discuss, especially in Asia (Chen et al., 2011). However, the Tokyo English Lifeline (TELL), Japan's largest suicide prevention NGO, tackles this discussion actively. In this globally connected time, we need to learn from each other, drawing on our experiences to become more efficient, better informed advocates. Some obstacles are unique to certain cultures, and some hurdles are universal. Suicide prevention is message that needs to be talked about, and like TELL, we all need to speak up. 

The Japanese word ganbaru represents a sense of perseverance in hardship, although it is commonly used alongside words like gaman, referring to suffering in silence. The Japan Times highlights how these phrases can paradoxically reinforce feelings of isolation (Jones, 2015). The issue of ostensibly well-meaning language being dismissive is, unfortunately, not culturally bound to the Japanese language, as I am reminded of the UK's classic 'chin up'. Around the globe, people erroneously believe that talking about suicide may make the situation worse. Tragically, with one person dying by suicide globally every 40 seconds (WHO, 2019), it is clear that silence is not the answer. 

TELL speaks out loudly and frequently, holding numerous large-scale charity fundraising events such as the Tokyo Tower climb and silent auctions, as well as smaller scale marches across Japan. These marches occur throughout the year and happen all across Japan, not just in Tokyo, but all the way in Kansai and even Okinawa. They increase visibility, they create awareness and they spark conversations.

I was inspired by their work and wanted to bring this active voice to my home. While I may not be able to replicate Tokyo Tower climb in my University town, I thought that a suicide march would be an accessible, visible, and most importantly, replicable awareness event. 

During my time as a TELL intern, I was fortunate enough to collaborate with brilliant minds and learn from hard working therapists, outreach coordinators and support line volunteers, all working tirelessly to raise awareness for suicide. This energy reignited my passion for advocacy and gave me new focus and inspiration to hold a suicide prevention march at my university. As an advocate for suicide prevention, I learned from TELL the value of being positive, informed, and taking an active voice – both online and in person. 

The first step was planning the event. I chose a day towards the end of term that did not clash with any existing events. Inspired by TELL's reusable cotton bags printed with their logo and lifeline number, I decided to design a similar bag for this event. With ideas and guidance from friends, I sent off the finished design to various vendors. Armed with my College Welfare Association budget, and thoroughly grateful for a charity discount, I was able to print out 100 cotton bags for the event. The slogan read 'Walk with Us, Talk with Us, Suicide Prevention' with the Samaritans phone number in the corner. 

Drawing inspiration from TELL's collaborative voice, I reached out to my College LGBTQ+ association, acknowledging the disproportionate effect that suicide has on LGBTQ+ youth (Barnett et al., 2019). Working closely with this organisation elevated the conversation to a broader platform, allowing it to reach even more students. The association's president loved the idea and took it a step further. She advertised the event within the association and on social media, raising awareness about how suicide affects the LGBTQ+ community. 

Excited by this feedback, I decided to reach out even further to the college's environmental association, since the march involved reusable tote bags that are an alternative to plastic. Pretty soon, this one event with a simple message involved collaboration with the LGBTQ+, Environmental and Student Welfare Associations with an open invitation to any other groups that wanted to take part. I am proud that I was able to, at least on a small scale, replicate TELL's collaborative approach to raising awareness. It is clear that a holistic and inclusive approach to the conversation is key because suicide affects people of all demographics and ages (WHO, 2019). 

With 100 bags printed, the event was just four days away, and the Facebook event was receiving interest from countless people... the event was cancelled. For the safety of students, staff and the general public, Durham University ceased large gatherings of people in early March of 2020 due to COVID-19. 

While a group march was out of the questions, the central focus of the event was to raise awareness and start conversations, which was still possible. So, the event was quickly adapted. Some other volunteers and I sat in college explaining the event and allowed students to take a free printed bag from a (regularly disinfected) box over the course of three days. We encouraged people to get their friends and family to cover the bags in signatures with marker pens. This idea came from TELL's marches, where each signature on a bag represents a conversation about suicide. 

The message resonated with home students as well as international students, and people from all backgrounds came forward, took bags and engaged in conversations. I felt grateful that these bags would be carried home by students to various countries, increasing visibility and sparking conversations in Shanghai, Beijing, Rome, Johannesburg, Miami, and many other cities. Notably, St Mary's college houses students from Teikyo University as part of a student exchange programme. As I sat outside the dining hall, conversing with these students in my broken Japanese, I was excited to share with them that this idea was inspired by a Japanese organisation.  

Sensitivity to cultural variation is important because varying triggers or factors may contribute to the onset of suicidal ideation (Goldston 2008). Effective advocacy strategies must therefore be adapted and modified to suit different countries. One universal aspect of prevention is awareness.

Of course, effective and long-lasting suicide prevention relies on the coordination of many efforts. Governmental policies regarding health care training, informed access to specific products, and empirical data are crucial (Bachmann, 2018). Similarly, on a smaller scale, one-to-one conversations are also an integral part of this journey. Why are conversations so important? Research shows that talking openly about suicide does not stimulate suicidal ideation itself, but rather reduces its likelihood (Barrero, 2008). 

Emotional support and openness is critical, but can also be incredibly daunting for both people involved in a conversation. For information and advice on how to communicate with, or support a loved one in need, please refer to Samaritan's resources, TELL's resources and NHS resources.

Global epidemiological data highlights that European and Asian countries face broadly similar obstacles. For instance, mental health services are chronically underfunded (Yip & Law, 2010) and many developed countries lack central, governmentally coordinated suicide prevention efforts, instead relying on NGOs (Chen et al. 2011). Policy decisions are often out of the public's control, and these decisions vary vastly between countries. By contrast, local scale, active efforts can be adopted and adapted universally, and accumulate to form a larger social impact. 

Every conversation about suicide is a small, yet critical step towards suicide prevention. Despite being a very real aspect of people's lives, conversations about suicide remain shrouded in stigma and shame. By learning from other cultures and taking on their practices, we are united as more informed, effective and motivated advocates for suicide prevention. 

With only a quarter of those experiencing a mental disorder reaching out for support (About-Mental-Illness), it is more essential now than ever to be active in our efforts. It is important not just to break the stigma but, as TELL puts it, we must 'shatter the stigma'. 

- Kyle Kelleher is a psychology undergraduate at Durham University. [email protected]

Suicide call lines:

• Samaritans - for everyone 24 hours a day Call 116 123
• Childline - for children and young people under 19: Call 0800 1111 
• Papyrus - for people under 35: Call 0800 068 41 41 – Monday to Friday 9am to 10pm, weekends and bank holidays 2pm to 10pm, Text 07860 039967
• Campaign Against Living Miserably (CALM) - for men Call 0800 58 58 58 – 5pm to midnight every day
• Switchboard LGBT+ helpline - Call 0300 330 0630, open 10am-10pm every day
• For those in immediate danger, call 999

Supporting a loved one:

• Samaritan's resources
• TELL's resources
• NHS resources

More on suicide in The Psychologist archive

References

About Mental Illness. (n.d.). Retrieved from https://bringchange2mind.org/learn

Bachmann, S. (2018). Epidemiology of Suicide and the Psychiatric Perspective. Environmental Research and Public Health. doi: 10.3390/ijerph15071425

Barrero, S. A. P. (2008). Preventing suicide: a resource for the family. Annals of General Psychiatry, 7(1). doi: 10.1186/1744-859x-7-1

Barnett, A. P., Molock, S. D., Nieves-Lugo, K., & Zea, M. C. (2019). Anti-LGBT victimization, fear of violence at school, and suicide risk among adolescents. Psychology of Sexual Orientation and Gender Diversity, 6(1), 88–95. 

Chen, Y.-Y., Wu, K. C.-C., Yousuf, S., & Yip, P. S. F. (2011). Suicide in Asia: Opportunities and Challenges. Epidemiologic Reviews, 34(1), 129–144. doi: 10.1093/epirev/mxr025

Goldston, D. B., Molock, S. D., Whitbeck, L. B., Murakami, J. L., Zayas, L. H., & Hall, G. C. N. (2008). Cultural considerations in adolescent suicide prevention and psychosocial treatment. American Psychologist, 63(1), 14–31. doi: 10.1037/0003-066x.63.1.14

Jones, C. P. A. (n.d.). Too much 'ganbaru' could push anyone over the edge. 

Suicide data. (2019, September 27) 

Yip PSF,  Law YW. , Towards Evidence-based Suicide Prevention Programmes, 2010Geneva, SwitzerlandWorld Health Organization