Suicide Prevention and New Technologies

Evidence Based Practice

B. Mishara, A. Kerkhof, B. Mishara, A. Kerkhof, B. Mishara, A. Kerkhof

• Publisher: Palgrave Macmillan
• Year: 2013
• ISBN:
  9781137351692
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

The internet, smartphones, computer self-help programmes and other technological advances are the new frontiers of suicide prevention, with organisations around the world rapidly expanding these services. This book provides a critical overview of new technologies in suicide prevention and presents promising practices and future perspectives.

1

Suicide Prevention and New Technologies: Towards Evidence Based Practice

Brian L. Mishara and Louis-Philippe Côté

Throughout most of human history people with personal problems would need to seek out another person to obtain help or emotional support. The alternative was to deal with the problem oneself, pray for divine intervention or have some solace from religious beliefs. In more recent times, for those few with the ability and culture to do so, one could also seek information, guidance or support from printed books. The second half of the 20th century was a period when the use of face-to-face professional help expanded throughout the world. During this same period, books became a source of a “do-it-yourself” psychological treatment, with an exponential growth in self-help books for almost any human affliction. In the mid-20th century, a new technology, the telephone, expanded the options for help seeking. Telephone support for suicidal people expanded rapidly since the start of the Samaritan movement in the United Kingdom, founded by Reverend Chad Varah in 1953 (Mishara, 2012). Today, telephone helplines provide crisis intervention, emotional support and suicide prevention services throughout the world. For examples, Befrienders Worldwide has affiliate helplines in more than 40 countries that provide telephone help based upon the Samaritan approach.

Toward the end of the 20th century we witnessed a radical change in help-seeking behaviours, more prominently in developed countries, but rapidly expanding almost everywhere. Today the primary source of information and help for young people considering suicide is the Internet, and the Internet is becoming the principal source of information for all age groups. Furthermore, a large proportion of help seekers on the Internet are looking for information for someone else (54 per cent according to a US survey of Internet users (PIP, 2000)). The Internet has also become a major means of communications among friends and is increasingly used by people in distress to try to obtain help. The first large-scale Internet-based suicide prevention service was probably begun in July 1994, when the Samaritans of the UK and Republic of Ireland started to respond to e-mails from all over the world from people seeking emotional support (Armson, 1997). Within a few years they were receiving over 500 messages a day, and over 50 per cent of the e-mails expressed feelings of despair and suicide. These messages are automatically sent to over 150 branches and are answered by volunteers who work on the telephone and have received special training on how to reply to e-mail messages.

There is a substantial gap between the exponential growth in use of the Internet to seek help and the slow, sometimes reluctant involvement of professionals and volunteer help givers in providing help over the Internet. This chapter presents an overview of our current understanding of the various current uses of new technologies in suicide prevention, with an emphasis on Internet services. Theories and research on new technologies are still in an embryonic stage, where most of the important issues are just beginning to be explored. Nevertheless, we now have some theoretical perspectives and empirical data to help orient practices.

We live in an age when the emphasis is on what to do, with little concern for the theoretical underpinnings of our behaviours. Mishara and colleagues (2007a) reported that when they asked telephone helpline directors to explain what helpers were taught to do over the phones, they could provide detailed descriptions. However, when asked why they used those particular intervention methods, they often had little to say, other than to explain that that is what they were taught to do. There was rarely any theoretical or empirical explanation for their current practices. Now, as empirical studies of telephone help are being conducted, we know better what works and what is less effective, and we have better support for some theories than others (e.g. Mishara et al., 2007a; 2007b). In examining practices using new technologies, we often find that methods of intervention are simply transposed from telephone help or face-to-face psychotherapy, with little or no empirical validation of the effectiveness of using these approaches with new technologies. However, there are now some theories and empirical data about new technologies that can offer guidance. This chapter discusses some general theories and their application.

New technologies also pose new ethical challenges. The specific issue of ethical issues in the control of websites that encourage suicide is the subject of the chapter in this book by Mishara and Weisstub (Chapter 5). However, there are ethical choices involved in the use of all new technologies. Again, these choices are rarely explicitly discussed, despite their important implications. The ethical challenges all tend to centre around the rights and obligations of helpers to engage in various suicide prevention activities, with or without overt requests for help from potential suicide victims. Resolving these ethical issues involves the clarification of moral assumptions about the right for people to choose to kill themselves and the obligations in a just society to protect life and help vulnerable populations (See Mishara & Weisstub, 2005; 2007; 2010, for a detailed discussion of these ethical perspectives and their application in suicide prevention).

Some examples to set the stage

This book presents suicide prevention initiatives using new technologies and their application. However, new technologies are not just used to seek help, and help seekers often do not obtain the help they are looking for. Below are a few examples of the range of situations one often encounters:

1. In September 2012, Tyler Clemente, an undergraduate student at Rutgers University, in New Jersey, jumped from the George Washington Bridge after his roommate filmed him having sexual relations with another man. He posted his suicide plans on Facebook. Just before jumping his last post read “Jumping from GW Bridge. Sorry.”

2. On Christmas in 2010, a woman in England who had 1082 friends on Facebook posted this message: “I took my pills, I will be dead soon, so good-bye everyone.” Many friends did not believe her; some called her a liar, and no one reported her suicide attempt. She died.

3. The Samaritans of the United Kingdom is one of several suicide prevention helplines that responds to SMS text messages. A not uncommon message these helplines receive reads: “I have had enough. I can’t continue living.”

4. Every day, discussion groups are visited by numerous people discussing their suicidal intentions. One forum in 2012 included the following exchange:

– Jacques (16 years old): “Everyone would be better off if I were dead”

– Sylvie (says she is an attractive 16 year old but is actually a known “predator”, a man aged 54 who enters discussions on suicide assuming a false identity to encourage people to kill themselves): “Life sucks – I found a good way to end it. So should you. Follow this link to see how to kill yourself easily, painlessly and you won’t mess up. I am going to kill myself too. I know how you feel; there is no way out. I’ll do it with you.”

The number and variety of examples one could cite are immense. One can only conclude that the extensive use of the Internet by suicidal individuals, the extent of help seeking and content that encourages suicide make it imperative that caregivers embrace new technologies and the Internet and as an important means of suicide prevention.

The variety of Internet users: what they are seeking on the Internet

Mixed Expectations: When a person walks into a therapist’s office, almost invariably something is troubling the person, and there is a clear expectation that the therapist will help with the client’s problems. Callers to telephone helplines, including those dedicated to suicide prevention, are occasionally prank callers who are just amusing themselves; there is even a small proportion who seek sexual stimulation from talking to a stranger, but the vast majority have some sort of problem for which they seek help. These problems range from feeling lonely to being in an acute suicidal crisis with a suicide attempt in progress. Again, the expectations are usually fairly clear: the caller is seeking help, and the helper, who could be a trained lay volunteer or a paid professional, is there to provide that help. However, contacts over the Internet do not require the identification of clearly defined roles. Internet contacts to organizations offering help constitute a very small portion of the Internet activity by suicidal individuals. Suicidal people most often discuss their problems over the Internet with friends and strangers. They can enter a forum; post photographs, videos and messages about their suicidal thoughts or intentions; chat with strangers and seek information about methods to commit suicide; assess their own suicide risk; or even find a partner with whom to commit suicide. There is no intrinsic screening process to identify who is seeking help, which users of which sites are at significant risk of attempting suicide, and which may be considered at low risk or are using the Internet for frivolous purposes. Still, there are a number of clearly identified “danger” signs and indications of an impending or ongoing suicide attempt. People announce their intentions to kill themselves over the Internet on social media sites, there are even examples of real-time videos showing suicide attempts in progress, some attempters send or post farewell letters before their suicide, and some people actively search for the “best” means of ending their lives. Besides people at risk of suicide, there is Internet contact by people who are concerned about the possible suicide of friends or family members and who seek information about what to do to help the suicidal individual.

One may assume that everyone who uses the Internet to make contact or seek information concerning suicide is a potential client or target for suicide prevention activities, regardless of what they purport to be looking for. Some people use the Internet to glorify, publicize, announce or justify their suicide, some try to communicate to others that it is not their fault that they are committing suicide or even to make others feel guilty. People who are not actively seeking referrals or resources for help may still profit from obtaining information about where help may be obtained. Also, people who are not looking for other solutions may still benefit from unsolicited exposure to other ways of dealing with their problems and offers of help, and potential suicide attempts may be avoided.

Variety of Internet Activities: The range of Internet-based activities is constantly expanding and includes video sharing to ask for help and self-help computer programs online to deal with suicidal ideation (see Chapter 6). Online therapy is expanding, as are commemorative sites for people who died by suicide and suicide “games” where an avatar can commit suicide by a choice of methods, and all those activities are subject to controversy and debate about their benefits and dangers. For example, commemorative sites after a suicide may provide helpful support to people bereaved. However, the same sites may be seen as glorifying the suicide, and this could incite others to end their lives in order to posthumously “benefit” from all the attention they will receive and the contrition by people the potential suicide victim feels have been unkind. A study by Eichenberg (2008) of German Internet message boards found that “suicide forums” vary in the help or harm they may provide, with the majority of users seeking constructive help, and only a small minority seeking information on how to commit suicide or partners with whom to commit suicide.

Research has shown (Mesch, 2008) that the choice of different channels or means of Internet communication varies according to different motivations. Mesch (2006) concluded that participation in chat rooms and forums is often motivated by the need for specific, round-the-clock social support. People who need to expand their social network more often use forums and chat rooms, whereas people who want to increase their sense of belonging with their peer group are more likely to use instant messaging, SMS and social networking sites. The research on Internet friendship formation in adolescence and Internet use has focused on two hypotheses: 1) The Rich-Get-Richer Hypothesis proposes that adolescents who already have strong social skills will benefit from the Internet. Research shows that socially anxious and lonely adolescents turn to the Internet for online communication less often than non-socially anxious and non-lonely adolescents. 2) The Social Compensation Hypothesis postulates that lonely and socially anxious adolescents would prefer online communication to face-to-face communication because it is easier to control. However, research has shown that this often does not lead to them establishing new friendships (Valkenburg & Peter, 2011).

There is also some evidence that youth who engage in self-harm have different online behaviours (Mitchell & Ybarra, 2007). Youths who reported deliberate self-harm in the past six months were more likely than other youths to have a sexual screen name or to talk with someone known only online about sex (35 per cent v. 5 per cent) and to use chat rooms (57 per cent v. 29 per cent). Those who engaged in deliberate self-harm were also more likely to have a close relationship with someone they met online (38 per cent v. 10 per cent), and 76 per cent used instant messaging (Mitchell & Ybarra, 2007). Harris, McLean & Sheffield (2009) found that people at high risk of suicide who used the Internet reported less perceived social support from family and friends compared with other online users. They also found that suicide-related online users were less likely to seek help from friends and were more likely to seek help in Internet forums. Suicidal online users found forums to be generally supportive and useful (Eichenberg, 2008; Kral, 2006). They felt that communications with family, health care professionals and help sites were less satisfactory. It appears that suicide-related online users are willing to interact with others, but they have a strong preference for peer-to-peer communications, anonymity and un-moderated formats. These findings tend to support the Social Compensation Hypothesis to explain Internet use by suicidal individuals. According to this theory, people whose social relations are not satisfactory will compensate by seeking social support on the Internet.

Increasing numbers of people use Internet screening sites to determine if they suffer from depression or are at risk of suicide. Leykin, Munoz and Contreras (2012) assessed the depressive and suicidal status of 24,965 users of a depression screening site and concluded that a large proportion of users (67 per cent) screened positive for current major depression and current suicidality (44 per cent), including 7.7 per cent reporting a suicide attempt in the past two weeks. However, of those who participated in monthly follow-ups who had reported a recent suicide attempt, only 37.2 per cent were in treatment for their problems. This highlights a potential disadvantage to online screening. Internet screening usually leaves it to the user of the site to find help. The encouragement to get help the site provides is usually in the form of a written message to the user of the site. Unlike screening performed face to face, where the person conducting the screening can try to motivate suicidal individuals to seek help, make referrals to local resources and even hospitalize a person who is in danger of committing suicide, Internet sites are rarely able to provide local referrals, and their written encouragement to seek help may not be as effective as the insistence of a mental health professional in their community. In this study, the participants who used the screening site came from 86 different countries, making it difficult to include useful local information about resources.

There has been recent concern about the immense popularity of “Massive Multi-player Online Role Playing Games” (MMORPG). These games, where players use avatars to affront challengers in a virtual world, are often described as being addictive. Research has shown that players with problematic game use have low sociability, feel that they lack social support, and are more likely to have aggressive tendencies (Festl, Scharkow & Quandt, 2013; Sublette & Mullan, 2010). Wenzel and colleagues (2009) found, in a Norwegian study of adults, that more time spent playing these games was associated with greater likelihood that the players would report depression, suicidal thoughts and alcohol or drug abuse. A study by Messias and colleagues (2011) found that teens who said they played five hours or more of video games each day were more likely to be sad, have suicidal ideation and suicidal planning, according to a survey they conducted in 2007. This may be due to the tendency of adolescents with depression to isolate themselves, but perhaps get bored of their isolation and seek a surrogate ...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• List of Tables
• List of Figures
• Preface: The Future of Suicide Prevention at Our Doorstep
• Notes on Contributors
• 1. Suicide Prevention and New Technologies: Towards Evidence Based Practice
• 2. Expressing, Communicating and Discussing Suicide: Nature, Effects and Methods of Interacting through Online Discussion Platforms
• 3. E-Therapies in Suicide Prevention: What Do They Look Like, Do They Work and What Is the Research Agenda?
• 4. Reducing the Burden of Suicidal Thoughts through Online Cognitive Behavioural Therapy Self Help
• 5. Challenges in the Control and Regulation of Suicide Promotion and Assistance over the Internet
• 6. Mental Health Online: A Self-Report and E-Learning Program for Enhancing Recognition, Guidance and Referral of Suicidal Adolescents
• 7. Avatars and the Prevention of Suicide among Adolescents
• 8. Crisis Chat: Providing Chat-Based Emotional Support
• 9. The National Suicide Prevention Lifeline and New Technologies in Suicide Prevention: Crisis Chat and Social Media Initiatives
• 10. Results and Experiences of 113Online, a Comprehensive Dutch Online Suicide Prevention Platform
• 11. Suicide Bereavement Online: Sharing Memories, Seeking Support, and Exchanging Hope
• 12. Innovating to Treat Depression and Prevent Suicide: The IPhone @PSY ASSISTANCE Application
• 13. Promising Practices, Future Prospects and Research Agenda
• Index