Suicide and the Internet

Robert C Hsiung, Azy Barak, Denise Silber
1 University of Chicago, Chicago, USA, 2 Israel University of Haifa, Israel, 3 France Basil Strategies, France

In this workshop, we explore the topic of suicide and the Internet from three perspectives. First, we report a suicide in an online peer support group in the United States. Next, we present an online suicide prevention service in Israel. Finally, we address the ethical responsibilities of the administrators of sites like these. This is, to our knowledge, the first report of a suicide in an online group. The group was a peer support message board focused on mental health and managed by a mental health professional. The reactions of the group members to the suicide was as varied as might have been expected in "real life" and included the wish for more information as well as outright disbelief; feelings of sadness, helplessness, anger, and loss; physical symptoms; remembrances of the deceased member; self-reflection; and support for each other. There were questions about the boundary between "e-life" and real life. Should group members use her real name? Go to her funeral? The board appeared to function as an effective "holding environment." No group members reported injuring themselves -- or were reported to have suicided -- in response. Administrative issues included notifying the institutional review board involved (the group was at the time considered a research study), ensuring that additional resources were available for those coping with crisis, and establishing some sort of memorial. A concern regarding the memorial was suicide "contagion." In the end, it simply linked to selected posts: remembrances, songs and poems, posts written to her *after* her suicide, and posts of her own, including ones about a previous suicide attempt and on her philosophy of suicide. The memorial area may function as a virtual cemetery for the virtual community. Having the administrator establish it may in part have served to reassure surviving group members that he cared about the deceased member -- and, by extension, about them. SAHAR -- an original, free Israeli online service -- set itself the goal of arranging an online environment in which Web surfers in distress would not encounter confusion and panic, on the one hand, or incitement and recipes for suicide, on the other. Rather, they would get in touch with trained helpers who would listen to them; offer support, advice, and referral; and, if need be, act to save their lives. All of this is now offered through a free, easily accessible, exclusively online service. SAHAR offers to surfers a comprehensive, content-rich, and continuously updated Web site; individual support through e-mail or chat; and group support through several forums. Over close to three years of operation, over 300,000 people have used the various help channels provided by SAHAR. Approximately 25,000 personal contacts have been made with people in distress, over 50% of whom were clearly suicidal. In addition, over 500 people in severe distress have used and found relief in using the online support groups. In all cases, suicide was successfully prevented by providing emotional support, significant and badly needed information, and referrals to professionals -- or by last-minute rescue operations launched in cooperation with relevant authorities. Not a single suicide committed by a SAHAR referral has been identified so far. The enormous success of SAHAR provides additional support for the idea of using the Internet as a valid channel for psychological help. Online peer support groups and suicide prevention services present, like many innovations, ethical questions. Users need to understand the potential risks and benefits of using such sites and the alternatives to doing so. In particular, the sites should disclose to users the potential risks to their privacy posed by the electronic communication and storage of information and the safeguards taken to prevent unauthorized access to their personal data. Limits to their confidentiality, for example in situations of danger to themselves or others, should be explained. Electronic communication may make misunderstandings more likely. The sites should assure that the services they provide are of high quality. Individuals providing them should be competent to do so. It should be clear what procedures that the sites will, and that users should, follow in an emergency. The ability of sites to rescue anonymous users located far away may be limited. The evidence base for such resources needs to be developed. If the procedures are experimental, users should be so informed. E-health ethics guidelines may help the developers and administrators of such sites to design and manage them more effectively and assist potential users in making more informed decisions regarding their use.