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Pilots of the future: suicide prevention and the internet

2010; Elsevier BV; Volume: 376; Issue: 9756 Linguagem: Inglês

10.1016/s0140-6736(10)62199-x

1474-547X

Niall Boyce,

Focus Groups and Qualitative Methods

Niall Boyce reports on increasing efforts to understand the path that people with suicidal thoughts travel online, and to work out when and how to intervene. Samaritans founder Chad Varah was that most British of things: an old-fashioned gentleman with a pronounced enthusiasm for the modern world. Besides his work in suicide prevention, he promoted progressive attitudes towards sex education in Picture Post, and was the astronautical consultant to Dan Dare, the “Pilot of the Future” whose exploits thrilled the readers of the Eagle. So it is fair to say he would have approved of the latest innovation by Samaritans: a box with the organisation's helpline number (08457 90 90 90) that appears at the top of the page in response to searches for terms relating to suicide on Google UK. It has been there since November 2010: a small change, but a significant one. This is not by any means the organisation's first foray into cyberspace—that came as far back as 1992 with the piloting of the [email protected] email address—but it represents an important advance in the way Samaritans engages with the public, and an indication that it is keen to address the challenges posed by a future spent more and more online. The first of these challenges will be to bring some sense of rationality and proportion to the ongoing discussion about the role of the internet. Although the perception of the online environment as something novel is wearing off for adults—and is probably a source of complete bafflement to teenagers—its involvement, however tenuous, in any episode of self-harm, suicide, illness, or violence guarantees intense media interest. And behind these stories lurks the assumption—made in the absence of any solid evidence—that the use of the internet, and specifically social networking sites, is intrinsically damaging. In 2009, for example, the UK Sunday Telegraph ran an interview with the Archbishop of Westminster Vincent Nichols: it was reported that the Archbishop “warned that the sites are contributing to a trend for teenagers to put too much importance on the number of friends they have and that this can ultimately lead to suicide.” The balance of risks and benefits is hard to quantify. On the one hand, use of the internet can cement social connections, and provide an anonymous, confidential space in which to express oneself and find sympathetic listeners. The It Gets Better project, a site targeted at lesbian, gay, bisexual, and transgender youths, shows the power of the internet to reach out to individuals facing social isolation and adversity. On the other hand, the internet can be used in less constructive ways. It can be used as a method of bullying, and for the vulnerable it can provide free, immediate access to potentially harmful information and interactions. With regard to the provision of information, the concern that romanticising suicide, presenting self-harm as a solution to a problem, or explicitly describing methods might encourage imitation by others is nothing new. In the late 18th century, Goethe's novel The Sorrows of Young Werther described the protagonist's picturesque and ritualistic suicide. Reports of copycat incidents followed its publication, and its legacy lived on: the term Werther Effect was coined in the twentieth century to describe the phenomenon of suicidal behaviour modelled on media portrayals. Two recent reports from the Australian Mindframe National Media Initiative on the portrayal of suicide and mental illness assess the current evidence. Suicide and the Entertainment Media concludes that “there is a need to err on the side of caution”, and its companion report, Suicide and the News and Information Media, states that “presentations of suicide in news and information media can influence copycat acts in particular circumstances”. But what of the internet? Professor Jane Pirkis of the University of Melbourne, co-author of these reports, told The Lancet that it is “much harder to research than traditional media because it's such a changing medium—so the evidence base surrounding its potential for positive or negative impacts is much weaker than that for media like newspapers and television”. Nevertheless, the rapid, global spread of news over the internet highlights the need for reporters to consider their responsibilities when covering stories of suicide; there is a distinction between raising awareness in a positive way, and acting as a vector for dangerous patterns of behaviour. David Gunnell, Professor of Epidemiology at Bristol University, co-authored a British Medical Journal feature on suicide and the internet in 2008: he told The Lancet he is optimistic that there is “an increasing degree of shared understanding [between suicide prevention experts and the media] regarding concerns”, but pointed out that the speed and volume of information turnover mean “regular reminders” are necessary. Samaritans has produced guidelines to assist with this process, and continues to monitor and work with media outlets. However, Head of Policy and Research Clare Wyllie questions how much one can extrapolate from the old media model to the emerging world of user-generated online content. It is just one of the points they want answered. “How do vulnerable people use the internet?” she asks. “Why do they use it? What helps them? And what is destructive?” This is where another important factor comes into play: the interactive nature of the internet. The role of so-called suicide forums in facilitating pacts has been highlighted by professionals and the media: however, Samaritans questions whether there is a common understanding of what these spaces are, and the wisdom of a blanket ban. In any case, the hosting of such forums outside the UK means that such a ban is not legally possible. Professor Stephen Platt of Edinburgh University, who has carried out research on self-harm and suicide and is a Samaritans trustee, agrees that “banning these forums is arguably not the way to go”. An authoritarian approach risks driving the issue further underground—far better to find out how and why people end up in these online spaces, and how a positive, preventive alternative can be made appealing. “We need to maximise the potential of the internet”, Platt adds. “We shouldn't be concerned about only the negative effects—the positive potential has hardly been tapped.” This positive potential could take several forms. Mental health professionals might, in the future, be able to engage with their clients online using Cognitive Behavioural Therapy, for example. There could be the provision of secure, anonymous spaces on the internet to give distressed individuals the sort of constructive support Samaritans currently offers face-to-face and via phone, email, SMS, and post. Organisations like Samaritans have also established a presence on social networking sites. The USA-based National Suicide Prevention Lifeline provides some interesting examples of this. The Lifeline introduced a Google search mechanism similar to that of Samaritans in April, 2010: it can also be found on MySpace, Facebook, and YouTube. Queries regarding suicide posted to Help.com generate an automatic response with the Lifeline's toll-free number (1-800-273-TALK). Samaritans is even in touch with social networking sites about creating a system by which friends or family can raise concerns about an individual. There are many practical challenges, not least of which is to make the public more aware of the warning signs of suicidality, and its association with mental health problems including the misuse of alcohol and drugs. But for this to work, we need to know more. At this point in the story, we return to Chad Varah and the founding of Samaritans. As a young assistant curate in the Church of England, Varah was profoundly affected by the experience of officiating at the funeral of an adolescent girl; she had taken her own life fearing the start of menstruation meant she was suffering from a sexually-transmitted infection. From this event, he was able to delineate how things had gone wrong for her, and identify two forms of potential intervention for others in her position: education, and a sympathetic, non-judgmental listener. He was also able to provide the means—sex education classes (which, as he put it, labelled him as “a dirty old man at 25”), and the telephone. Suicide researchers now need to emulate Varah's approach: to understand the path that people with suicidal thoughts travel online, and to work out when and how to intervene. These are not easy questions to answer: future research will require a mixture of both quantitative and qualitative methods, examining both overall online trends and individual views. The work of Keith Harris at James Cook University, Australia, is already yielding interesting information: appropriately enough, his Suicide Study Group has a page on Facebook. It might help if we think of online space not as a separate, virtual world, but as an extension of this one, albeit with different modes and styles of interaction. It is an area that is ripe for new public health initiatives. Clare Wyllie points out that with their experience and expertise, Samaritans is already making progress. But it is not something they can do alone. Will the research community hear their call for action? For the Samaritans see http://www.samaritans.org/For the Mindframe Reports see http://www.mindframe-media.info/For the It Gets Better Project see http://www.itgetsbetter.org/For the Samaritans media guidelines see http://www.samaritans.org/media_centre/media_guidelines.aspxFor National Suicide Prevention Lifeline (US) see http://www.suicidepreventionlifeline.orgFor the Suicide Study Group on Facebook see http://www.facebook.com/pages/The-Suicide-Study-Group-JCU-Singapore/148265885183967?v=wall For the Samaritans see http://www.samaritans.org/ For the Mindframe Reports see http://www.mindframe-media.info/ For the It Gets Better Project see http://www.itgetsbetter.org/ For the Samaritans media guidelines see http://www.samaritans.org/media_centre/media_guidelines.aspx For National Suicide Prevention Lifeline (US) see http://www.suicidepreventionlifeline.org For the Suicide Study Group on Facebook see http://www.facebook.com/pages/The-Suicide-Study-Group-JCU-Singapore/148265885183967?v=wall