Since the influx of individuals signing-on for the first time, the Internet has become a microcosm of all the problems of society at large. Usenet, the messaging forum of the Internet, has been acutely affected by issues of morals and ethics. These issues range from children reading unmoderated, inappropriate newsgroups such as those in the alt.sex hierarchy, to companies disregarding Usenet precedence and tradition, deluging hundreds of newsgroups with their unwanted advertisements. Other on-line service providers, such as CompuServe and American On-line, have much stricter codes of standards and can enforce them through their membership structures. They also have formal organizational structures and moderators scan most discussion areas on-line. On the Internet, anyone can become a member at anytime and participate in any discussion anywhere. There is no formal organizational structure and very few moderators of newsgroups.
Tucked away in a few newsgroups are a number of individuals who are suffering intense emotional pain. Sometimes they express their pain by writing suicidal messages on a newsgroup. Other times, they may be on-line -- in real-time -- on the Internet's interactive chat forum, the IRC. Lurking on one of the IRC's hundreds of individual channels, these individuals might disclose their desire to kill themselves. Peers often counsel these people, offering support through their darkest moments. What, however, are professionals to do when they come upon these individuals in a forum, whether through a message posted to a newsgroup, or live, on an IRC channel? Many professionals who are on-line argue that the answer is a simple, "Nothing."
These clinicians and doctors argue (privately) that they have no responsibility to these suicidal individuals who are in so much pain because no relationship with the person has been established. "After all," goes their rhetoric, "the first thing we learned in our training was the importance and sanctity of the patient-therapist relationship." The truth of the matter is that these on-line clinicians may be simply trying to ignore their implicit responsibilities in an effort to absolve themselves of any future legal liability.
Imagine a doctor and his wife on the way to see the new play down at their local theater. Before the play, they have a quiet, romantic dinner at a local restaurant. During their dinner, a man at the table next to them suddenly clutches his chest and falls to the floor. The doctor's first instinct and likely first action is to rush over to the fallen man and offer his medical expertise and help. Why does the doctor do this? He has never met this man before in his life. His intervention, while possibly saving the man's life, has likely ruined his night out with his wife, or at the very least, changed the tone of it. The lost few minutes of leisure time, however, possibly resulted in the saving of another human being's life. Would the medical doctor be in an ethically or morally defensible position had he done nothing while the man lay on the floor, clutching his chest in pain? And yet, this is precisely the position many doctors and clinicians on-line have taken when examining their role in potential suicide victims' lives.
These clinicians might dispute that the analogy is not really compatible, in that the doctor is physically present with the patient, even as encountered in a restaurant. But a medical doctor needs the physical body of the patient in front of him to see, run tests on, diagnose, and ultimately treat; that is the nature of medicine and disease. Illnesses of the mind, on the other hand, need no such physical presence in order for the clinician to intervene, at least not in the immediate, short-term crisis model of intervention. Countless suicide telephone hotlines set up across the country prove just this very important point. When the first hotlines were set up decades ago, opponents argued that they would never work because strangers wouldn't talk openly and honestly with people with whom they have no relationship. It was theorized that because of the lack of a relationship, there would be no leverage to convince the callers to delay their suicides. But time has proven that the critics were terribly wrong in their assumptions about the viability of suicide hotlines. Since their inception, hotlines have saved thousands of lives. Neither a physical presence nor a preexisting relationship is necessary (nor sufficient) in order to prevent suicide.
Another argument used by clinicians on the Internet is that they feel angry and resentful that these suicidal individuals might interfere with their leisure time activities -- namely, exploring the Internet for entertainment, education, and relaxation purposes. "After all," they argue, "if we can't get away from the pressures and responsibilities of work through our chosen recreational activities, then why should we even bother to continue being on-line?" Just like medical doctors would stop going out if everywhere they went people were dropping to floor with illness, so would clinicians stop utilizing on-line services. The answer to this criticism is simple -- it's a matter of degree and societal norms. Not all people who are suicidal feel comfortable approaching a therapist in public and proclaiming their suicidal tendencies, nor should it automatically be assumed that they will do so on the Internet. While there is more anonymity on an on-line service, such anonymity is by no means guaranteed. Luckily, there are enough resources and caring clinicians already on-line that the time-constrained or untrained clinician could always refer the suicidal individual to someone else, after their initial intervention with that person. Suicidal individuals don't show up on every forum in droves every single day, so interventions don't need to be constant. Therapists who monitor the same forums, whether it be a newsgroup, MUD, or IRC channel, could share the responsibilities of intervening. After all, human life should not be measured in simple terms such as time or inconvenience.
"But why should I get involved? Someone else will surely help this person..." Individuals who get involved in the helping professions should understand the unique and intense emotional pain of human beings and -- as any medical doctor would rush to help someone suffering from a heart attack -- intervene whenever necessary to possibly save another's life. This should not be merely a choice, but rather an accepted responsibility of a clinician's lengthy and specialized training in helping individuals cope with emotional trauma. Untrained "help" offered to the individual by his or her peers might actually be more harmful than helpful, no matter how well-intentioned. As clinicians, we are in a unique position to offer our training to help save lives on the Internet and make a difference in people's lives. Some clinicians are probably now asking themselves what types of specific interventions would be helpful to suicidal individuals on-line. The answer -- the same interventions one would use with any suicidal patient or client who presented him or herself to you for treatment at your office. Although a clinician cannot hear the person's pain as one might if the person was sitting in front of the clinician or the clinician was talking to that person over the telephone, the intense negative feelings are still there. Interventions should be focused on the short-term, crisis-intervention model, where the clinician seeks to help prop up the individual's own coping strategies and resources and reaffirm a desire to live, if even for another 24 hours. A contract can be made with the individual to refrain from such attempts for a set period of time, and, write back to the clinician immediately if he or she is feeling suicidal. If someone is imminently suicidal and in danger of hurting themselves, a clinician's best action would be to try and contact that individual's institution (if from an .edu domain or .com site) and/or the root administrator at that person's site. On-line interventions such as these have been known to save people's lives.
During the first intervention with suicidal individuals on-line, clinicians should provide the person with information on support resources available to them on the Internet. Two of the most popular resources are newsgroups, alt.support.depression and alt.suicide.holiday. Both forums allow people who are contemplating suicide a place to go and write public messages about their feelings and read replies to their messages. The drawback to these public forums is that unless the individual uses an anonymous remailer service, messages are public and identities are known. A mailing list, Walkers In Darkness, is also available to those who would rather keep their pain more private. Although a mailing list is also public, it is read only by the other people subscribed to the mailing list, usually a much smaller population than those who read newsgroups. People can subscribe to this mailing list by sending an E-mail message with the text: subscribe walkers to: email@example.com. A third resource available to those on the Internet are The Samaritans, a group of volunteers who offer unconditional support to those who are feeling depressed and suicidal (they do not answer questions). People can write to them confidentially by sending an E-mail message to: firstname.lastname@example.org or anonymously to: email@example.com. By providing the suicidal person with these additional resources, clinicians can help ensure that the person has additional support from within the Internet community.
The goal of the professions of psychology, social work, and psychiatry is to try to grasp a better understanding of human and social behavior and psychobiology to ultimately improve individual's lives with more timely and effective treatment interventions. Rather than cowering behind the cloak of the common, tired, and well-worn shield of "professionalism," clinicians should seize the duty, honor, and responsibility of society's call to them and their unique talents by utilizing their training and skills on-line. The need already exists. The only question that remains is whether the helping professionals on-line will lead or follow others when it comes down to assisting people choose life over death.
Last reviewed: By John M. Grohol, Psy.D. on 9 Oct 2013
Published on PsychCentral.com. All rights reserved.
I've wrestled with reality for 35 years, Doctor, and I'm happy to state I finally won out over it.
-- Mary Chase