Mentorship | Mental Health

Bind Skeja: Stigma is the main thing that inhibits people from seeking help

By - 25.12.2019

The ‘Lifeline’ founder speaks about mental health, suicide, the role that society can play and his project to help people in crisis.

Depression is not an illness — in the literal sense — that only affects a few people. Other people are not free from the struggles that it brings. In fact, depression is connected to a series of emotions, thoughts and behaviors that are in everyone. Every once in awhile, almost everyone loses interest and finds no joy in activities, has trouble sleeping, gains or loses weight, feels guilt, thinks of themselves as worthless or ruminates on death. No “symptom” of depression is alien to anyone, but what differs is simply the intensity. The severity of symptoms changes from person to person, or from day to day for the same individual. 

The biggest problem with mood swings is their close connection to suicidal behavior. Major Depressive Disorder (MDD) is the main precursor of suicides, according to experts. The American Psychiatric Association found that 15% of people who suffer from MDD end up committing suicide.

While studies show that within a year, 6.6% of American adults and 4.4% European adults fulfill the criteria of the Diagnostic Manual (DSM) for diagnosing MDD, in Kosovo there are no statistics that show the prevalence of this disorder. Psychologist Bind Skeja suspects that the actual number of suicides is higher than the reported number. He says that deaths caused as a result of intentional overdose are not categorized as suicide. Moreover, suicide attempts often remain unreported due to stigma.

Since the end of the war, 1,132 people committed suicide in Kosovo. The number of reported suicide attempts is twice as high. On average, every week one person commits suicide. Three others attempt to commit suicide. Statistics might not show the correct number because of societal taboos, unreported cases and a tendency toward secrecy. This situation requires serious treatment. 

To address this, a few young people took the initiative to establish Lifeline, a telephone helpline for people with suicidal thoughts. Kosovo 2.0 spoke to Bind Skeja, founder of the center. Bind has a degree in Experimental Psychology from the University of York in England. He manages the Lifeline project at the Center for Information and Social Improvement, which he also founded. 

Since the war in 1999 until today, 20 years later, severe economic conditions and rapid social changes continue to affect our lives. How do they relate to mental health? 

One mistake that people make very often is connecting depression to severe economic conditions or life events. Without a doubt, they are risk factors. But they do not necessarily lead to depression or suicidal thoughts. 

There are many people who have very good lives — from the outside — they have good relationships with their families, feel harmonious, have money, jobs, time and opportunities to travel, to have fun. But nevertheless, they suffer from depression.

If we look at the economic factor as the cause of the problem, it can lead us to the false belief that by helping someone financially, we can mitigate their depression.

Studies that measure the relationship between poverty or unemployment and depression note that the effect of these variables is much more peripheral, rather than being the core of the issue.

We must keep in mind that depression also has a biological dimension. So interaction between biological and social factors is required to produce a suitable environment for depression. However, people who are very poor have few financial opportunities to seek help. They also have fewer social connections to use to tackle the issue. 

For example, in Kosovo, a psychotherapy session costs 20-25 euros. Free psychological services are provided by the state, but are poor quality. In short, If predispositions for depression exist, living in severe conditions can increase the chances of this problem surfacing. 

But we can’t simply say: “X person has economic problems. Consequently they suffer from depression.” If we look at the economic factor as the cause of the problem, it can lead us to the false belief that by helping someone financially, we can mitigate their depression.

Photo: Altin Gashi / K2.0.

How aware is our society about the importance of mental health?

There are big differences within Kosovar society: Geographic, demographic and others. If we look at Prishtina, we see that people in general are more open-minded. Especially younger generations who are quite interested in learning more about and discussing mental health.

I believe that school is also a factor that pushes forward these issues. For example, pupils today learn about bullying and talk openly about problems of this nature. But how much are they dealt with at the higher levels? That is a whole different issue.

In villages mental health is seldom discussed. Even in other cities, for example in Peja, Gjilan, Gjakova, these issues are still taboo. In general, we are in the understanding phase, but we have not yet reached the action phase. So, we know that problems exist and we are aware that we need to discuss them. But on the other hand, we aren’t taking concrete actions.

As with every other issue, open discussion helps with mitigation.

There is progress, but it is slow. The situation is better than it was ten years ago, to a certain extent. But there is much more work to be done to reach a level where people are aware of depression, disorders, anxiety etc. They are normal, human conditions.

What is society’s role in solving the suicide issue?

Like poverty, which can be considered a risk factor, social support has the opposite function. It is a mitigating factor. More space for discussing problems translates to more ability to understand and control them before you reach a critical point. Like suicide. 

As with every other issue, open discussion helps with mitigation. Isolating and closing oneself off can make the problem worse. If it doesn’t lead to suicide attempts, it surely leads to living a low quality life. That is another big problem.  

Do you have data on these issues from the past? Is the phenomenon of suicide more prevalent today? How urgent is it? 

The problem with this data, at least from my perspective, is that they are not very representative of the real situation. This is mainly due to societal taboos. Many suicide attempts are not reported. When police intervention is not necessary, cases can be kept secret. This doesn’t happen only in Kosovo, but all over the world.

It’s hard to believe reports about the number of attempts. 

There is also another problem: Suicides can be reported in different ways. Some cases can look like an accident and we can’t be sure whether it was an intentional action or not. This creates a gap. An opportunity to manipulate the cause of death.

In Kosovo, the young are more prone to suicide.

In our society, there is also a religious motive for hiding suicide. It is reported as an accidental or natural death, to avoid being rejected by religious representatives for burials. Some believe that if a person is buried without religious rituals, they won’t go to heaven. 

All of these factors contribute to the phenomenon of keeping suicides secret, which influences statistics. There is already a shortage of data.The Social Lab organization gathered data and is preparing a report. But this takes time and requires lots of work. 

In general, what ages are most susceptible to suicide?

In other countries, European countries, usually the age group that is most affected is the middle-aged. Men in their forties who aren’t married or in a relationship often suffer from depression and are more likely to commit suicide. This is because they live alone and lack social support. They have no one to talk to. They see that they haven’t achieved their goals in life.There is no one to lend a helping hand during their period of loneliness. 

In Kosovo, the young are more prone to suicide. There is not enough data about why this is the case. 

What influences people to harm themselves or commit suicide? 

A lack of hope and a lack of support. When social media is harmful. Or simply when they have no one to support them when they start having suicidal thoughts. How these thoughts are created is very individual, subjective. Usually they are rationalizations of the depression that they already have. 

Research studies that have tried to find a common denominator — a factor that makes people identifiable as potentially suicidal — have only pointed out earlier suicide attempts as an indicator. Nothing else was found. 

Often people who have a history of suicide attempts end up committing suicide. What are people who unsuccessfully attempt to kill themselves trying to say? 

It’s just a myth. Some say that people who try to kill themselves do it just for attention. That is wrong. A person who attempts to commit suicide doesn’t try to convey any message. It can be read as ‘life has been unbearable for me.’ This is not a message that a person tries to tell others. But a feeling that, perhaps, they found no space to express or share. 

There can be cases where suicide attempts are another way of seeking help. However, this must not lead to the prejudice that there is always a message behind self-harming behavior. In fact, such a belief contributes to the stigma that surrounds it. 

Does Kosovo have the institutional capacity to provide aid in such cases?

If there is no [institutional] capacity, there are organizations that are quite prepared to provide aid. However, the state must be ready to provide aid. If not financial aid, then at least provide legal support by creating a legal infrastructure to increase capacities to deal with the issue of suicide.

Cases must be dealt with in ways that are scientifically proven to be efficient. Not through self-invented methods.

I had a meeting with the current Minister of Health, Uran Ismaili, and he promised support. But beyond words, nothing was done. We hope that the new government will increase cooperation. 

Mental health centers are very weak. State control is minimal. Some of the staff are unqualified. There are evident cases of misuse. There are even confidentiality breaches. When this happens we can no longer talk about psychological treatment. Indeed, there are psychologists who are truly capable and prepared. This gives me hope. However, we must not forget that things can improve.

We urgently need reforms, especially with staff recruitment. We need to employ clinical psychologists in a just, transparent, merit-based way. Cases must be dealt with in ways that are scientifically proven to be efficient. Not through invented methods.

Photo: Altin Gashi / K2.0.

To what extent does the stigma that surrounds mental health prevent people from seeking help? Do you think this is a problem that is exclusive to Kosovars? Or is it prevalent in other countries as well?

Stigma is not exclusive to Kosovars. It is a problem around the world. Developed countries have begun dealing with it. While here it is still ignored. For example, in England, Prince Harry appeared on BBC along with a few footballers and spoke about depression and other mental disorders. Taking male role models who are considered “super macho” and speaking with them about their experiences of anxiety and fear is quite a strong attack against taboo and stigma.

Meanwhile in Kosovo, the fight against stigma remains on a lower level, mostly led by NGOs. It has not yet been included in the state strategy. This is the main barrier that inhibits people from seeking help. 

Let’s move to more concrete questions about your initiative: What is Lifeline?

Lifeline is a telephone helpline for suicide prevention. People who have suicidal thoughts can phone us. 

Who answers the call from the person seeking help?

On the other end of the line is a volunteer who was trained by the Dutch Helpline 113. The 113 Helpline also serves people in crisis. The volunteers aren’t necessarily of the same profession or background. Some are psychologists, jurists or engineers. What we need is for the volunteers to be empathetic and good listeners. People who can endure the stress that the job brings. The training they get gives them the ability to do the job. The training is quite intensive and is very efficient for preparing staff.

How does Lifeline work?

During the call they converse. We and the volunteers, are prepared to face a person who is at their critical point. Who is thinking about committing suicide. 

The volunteer has to take the person out of the crisis they are in and guide them to where they can make more rational decisions. Then they can make long-term plans to seek help. There are different ways to approach a person in crisis. The most important, is to keep the conversation going. 

Very often, people who have suicidal thoughts or behavior have reached that point because they couldn’t find other solutions. The reason they couldn’t is because they didn’t discuss it with anyone else. So sometimes having a simple conversation about their problems, where both people acknowledge that having concerns and problems is normal, is enough to make them rethink their plans about killing themselves. 

Indeed, this is not a long term solution. But it can stop someone from attempting suicide. So the idea is to prevent the suicidal act. Then a person can seek psychological help. 

When is the line active?

Every day from 21:00 to 01:00.

Why at night?

The previous helplines that we were in contact told us that at this time they received the most calls. The idea was to have longer working hours. But because of the lack of volunteers and conditions, initially we are open for four hours only. Later, with more volunteers and more training, we will try to extend our working hours. 

The preservation of confidentiality is sacred.

If we can find support, we want to make it functional throughout the whole day, with no interruptions. However, we are exclusively volunteer run. The most we will be able to do is eight hours, from 19:00 to 03:00. For 24 hour access we would need support from the state.

How did you come up with this idea?

Helplines exist in every country. In fact, in England every region has one. The same can be said for Indonesia. Helplines exist in the Balkans as well.

There is no reason why Kosovo shouldn’t have a helpline. Somewhere people have another human being who is ready to listen to them. It’s something basic, which doesn’t require much work. It is something that even a young person like me, a 24 -year -old, has managed to do. I was really self-motivated and that gave me the wings to take this step. It is very easy, very simple, easily implementable, but it has never been done. So I said to myself, if no one else is doing it, I will. Lifeline is the result of persistence. 

Do you have issues preserving the confidentiality of people who call?

The preservation of confidentiality is sacred. It is not at all difficult to preserve what is said in faith. It is very easy. You simply don’t discuss what was said outside of the line.

Only three people can know the content of the conversation: The person who makes the call, the volunteer who receives it, and eventually another volunteer that can provide help. Not a word can be said to another person. The data isn’t saved or recorded. So we can’t even use the calls for statistics.

Whoever is on the line, the moment they hang up, we lose any connection to them.

Do you have psychological support or oversight for volunteers? Because they could also become emotionally troubled from the work they do.

We are in contact with a psychologist who has agreed to provide group psychotherapy for the helpline volunteers. The first session was held a few days ago. Sessions will be held every month and are free of charge. But even I — since I don’t receive the phone calls myself — am ready to oversee the employees, provide support, to see if someone is feeling troubled. So the staff are not alone in this.

How many people seek help within a day?

It varies. Days differ radically. We are not active for long periods, so we cannot even calculate an average. Some time has to pass before we can talk about figures, trends and whatnot. It has only been three weeks since we started. In the beginning there was a huge influx, but now we’ve noticed a decline. But, let’s wait…

A person calls, tells you their problem and you provide help. But what then? Do you check if the callers have harmed themselves? If they’ve gotten past the crisis?

The call is completely anonymous. We don’t know who the person calling is. What their name is. Where they live. We do not even see the number they are calling from. Even if we want to check up on them, we cannot find them. So whoever is on the line, the moment they hang up, we lose any connection to them. We can’t know if the call had an effect. If they’ve turned to someone else for help, or anything else. It is the caller’s responsibility to seek long-term help. Or they can call us again.

Suicidal thoughts are dangerous, a person’s life is endangered as a result. Depending on the cases that you receive, can you report it to the police or some other institution if the case is extreme? Or when you think that your help is failing to avoid a catastrophe? 

To preserve confidentiality we do not take a person’s data. This practice makes it impossible to report the case or include a third party to solve the situation. 

This has two sides. On one hand, our hands are tied. We cannot report the case. No matter how extreme it is. On the other hand, this makes us more trustworthy. We can provide people with an opportunity to share their problems without fearing that other people might find out. This is the price we pay to be more trustworthy, to enable more people to call and consequently to prevent more suicides. 

If a person calls and gives their data, according to the criminal code we are obliged to phone emergency services when we judge that a person’s life or health is in danger. But this is not our objective. When we see that the situation is out of control, we can suggest that they call the police or another institution. However, we cannot do that for them.

Suicidal thoughts are often symptoms of mental disorders such as major depressive disorder, bipolar disorder, etc. So there are people who suffer from these disorders and experience recurring suicidal thoughts. Can you offer to arrange meetings for them with mental health professionals? Perhaps to initiate some psychotherapy program?

We cannot do this directly. But we have a list of psychologists that we can share with the caller. 

Can a person who is close to the person in crisis make the phone call?

By all means. We have a protocol for how relatives can approach a person in crisis, to help them avoid suicidal actions.

How can their relatives identify a person who is experiencing a mental crisis or is prone to commit suicide? 

By speaking openly. This paves the way for people to open up about their problems and concerns. But there is no clear, safe sign that is notable to the untrained eye. What they can do is create a climate that enables the person to express him or herself.

There are families who provide support, help, space, everything to a person with suicidal thoughts, but the tragedy still happens.

There is a myth that people who commit suicide are under the influence. In fact, suicides are often planned months before. That is why space for conversation creates circumstances to identify people who are planning to take their own lives. There is no other way. 

There are people who are very functional, look healthy, have no obvious symptoms, yet suffer from depression. If you want to know whether or not you have people around you who are thinking about committing suicide, just be empathetic listeners, give others space to talk. This doesn’t mean pressuring them: “Tell me, tell me what’s bothering you…” I am talking about creating circumstances where a person doesn’t feel judged, but feels relaxed, free to share concerns with another person that they trust. 

However, there are cases when you do everything perfectly — families who provide support, help, space, everything for a person with suicidal thoughts — but the tragedy still happens. This is a bitter fact that we must come to terms with: We cannot save everyone. That is why we must not blame ourselves if despite our attempts, they still decide to end their life. 

In Lifeline, we try to help people. But if we do not manage to prevent someone from committing suicide, this doesn’t mean that we didn’t give our all. 

How many people are working on the project at the moment?

There are 11 volunteers, two managers and one designer. We plan on employing a few helpline functionality supervisors. We are in contact with a few psychologists who we want to include in the project. In January, we will begin to recruit more volunteers.

Photo: Altin Gashi / K2.0.

Is there a time limit for people who call?

No. Although if the conversation goes on for too long it can get repetitious. That leads to monotony and can be counter-productive. In addition to this, there could be other people who are waiting to connect. Every case is unique and must be managed as such.

How do you recruit volunteers? 

Dutch trainers have trained us. Uka[the other manager] and I train the others. We continue to stay in contact with the Dutch Helpline so we can receive instructions for improving our training abilities. But the next training will be lead by us. Anyone over 18 is eligible to apply. You can apply to be a volunteer by sending a message to linjaejetë Then we inform applicants about the next steps. The most suitable candidates are selected. We cannot have more than 20 people in the training.

Do you have a strategy for expanding the project throughout Kosovo? If so, how will you do this?

Everything depends on state support. If the state institutions provide the necessary aid, we can start to expand the line throughout Kosovo. The idea and project exist. However, if there is no funder, the idea cannot come to life. We are waiting to receive funds. If not from the state, then at least from non-institutional donors. This is the only way to expand our activity. We cannot make this happen by relying only on volunteer work.K

Feature image: Altin Gashi / K2.0.