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In October 2001 Professor Felber,the chairman of the German Society for Suicide-prevention (DGS), received from the BMBFS a letter with a set from questions regarding suicide fora on the Internet with the request for a statement. Since this topic was not discussed in the DGS yet, Professor Felber asked some executive committee members with some experience with the Internet for a personal statement. In November there was a discussion of the questions and statements in the Children's Welfare Committee of the Federal Assembly. The statement is presented in the English translation below. The original text in German can be found elsewhere

Suicide Fora on the Internet

original article by Georg Fiedler and Reinhard Lindner translated into English by euclid k.
Commentary by the translator has been inserted into the text and can be distinguished from the translation by the use of [square brackets]

Preface

When a 17 year old Austrian and a 20 year old Norwegian committed suicide by jumping from the 600 meter high cliff "Prekestolen" ( a well known tourist attraction in the Norwegian Fjord district), the official discussion about suicide fora on the internet became quite earnest.  The two had made contact on the internet in a discussion group that focuses on suicide.  The young man had posted a message there, soliciting for someone with whom to commit suicide together.  From the replies he received from a number of young women, he selected the one from Austria, who eventually traveled to Norway and jumped with him to her death.

This event was covered extensively by almost all the media, the suicide pact made on the internet being the sensational focal point of the coverage.  The effect was to give the internet a vague connotation of being potentially deadly and dangerous.  Subsequently the sensationalist reporters turned their attention to related topics, including suicide discussion fora, mailing lists and web sites, some of which have been around for quite some time.  The pioneering high point,[or would that be low point?] was the coverage by Spiegel and Spiegel-TV.1  This sort of coverage was highly dubious as it has emphasized not the actual dangers but rather the possibilities for acquiring information on methods of suicide.  The German Society for Suicide-prevention (DGS) has revised the present media-guidelines, and has organized a conference to be held in the spring [this was held in March 2002], at which time it will address the dubious aspects of such media coverage.

1 We do have some experience with the journalistic approach to this theme as one of the co-workers from our center was interviewed by Spiegel-TV.  The interviewing journalist strongly pressed for a simplistic statement that would support the sensational slant of "casualty of the internet"- which she certainly did not get.  The statements in the interview which were moderate and non-simplistic were not included in the coverage.  They were not wanted.

Unproven Assumptions and False Assumptions

Many people in the media who contribute to the portrayal of the "suicide-risk of the internet" start from assumptions that are erroneous, or unproven, or over-generalize from individual cases.  A paper by Solveig Prass, who is very involved in the discussion of suicide fora, is exemplary of this (Prass 2000).

Erroneous assumptions are:

  1. The communication via email, chat rooms, and fora on the internet should be decoded as ordinary verbal and written communication.
  2. Suicidality and other mental illnesses (e.g., personality disorders) can be engendered in individuals by the communications made through these new media.
  3. The participants in suicide fora on the internet are available for contact outside of this medium.
  4. The interpersonal dynamics and group behavior that takes place through these new media are to be understood in terms of a sect.

Unproven assumptions are:

  1. Reluctance to commit suicide is insidiously lessened in the suicide fora.
  2. Suicide methods information available in the fora increase the danger of suicide by the participants.

The discussion concerning suicide fora on the internet should have a factual basis.  The controversy over the internet could be expressed by an Analogy: is the internet a hammer or a magnifying glass?  Does the internet engender suicidality in youth (and adults as well), or does it rather make existing problems and subcultures visible?  We are inclined to say the internet is more like a magnifying glass.

Suicide Fora

With minimal effort one can find about 10 web based suicide fora in the German language internet (selbstmord.de, Freitod.de, ErwachsenenforumSuizid, OffenesSuizidforum, selbstmordhilfe.de, Schwarzer Abgrund, suicidaldreams, Hilfeforum, SuizidforumSoulfly, traeumerforum) some of which also offer mailing lists and chat rooms.  On Usenet we have not found any German language newsgroups using the search strings Suizid/Selbsmord/Freitod.  Not surveyed are the Internet Relay Chat (IRC) channels; it is possible to create ad hoc channels that can be named anything [and therefore it is difficult to ascertain the number of channels that would be of interest].  Beyond that there is an unknown number of non-interactive, pro-suicide web sites that offer advice on suicide methods.

The suicide fora seem to differ in their attitude toward suicide.  While in some the methods discussions predominate, in others the exchange of suicide fantasies and methods are not welcome.  Many fora have links to pages with suicide methods and devices, some also link to sites offering assistance.  Probably the oldest English language source is the Usenet newsgroup alt.suicide.holiday (a.s.h.), and it is the model for many forum-masters.  a.s.h. was created 1987/1988 to discuss why the number of suicides increases during the holidays.  Over the years the unmoderated group became a fora for the discussion of suicidality in general, beginning with information and discussion of suicide fantasies and suicide methods and coming to include literary and even legal, psychological, and philosophical approaches to the question.  Today the forum is accompanied by a voluminous web site with documents and links.  Currently a.s.h. considers itself a ‘subculture’, unified by the belief that people have the right to suicide, but that one should not press others to suicide.

The problem of suicide fora can only be understood in the context of society’s attitudes toward suicide.  The fora represent a free space, where one can examine and formulate suicidal thoughts that are otherwise taboo.  One must admit that in Germany there are few alternatives for suicidal youth.  And like the adults, as a rule they do not seek out psychiatric assistance.  The question of the problems with suicide fora is tied up with the question of what sort of alternatives juveniles have for the expression of these thoughts and where they can, if necessary, get help.

Communication on the internet

Any analysis of communication on the internet has to keep in mind the peculiarity of this medium.  Huang studied the question of what sort of communication patterns were on the internet and concluded:

The most difficult task for someone who wants to learn about the internet is not mastery of the technical aspects of communicating, but rather to become acclimated to the shifting of expectations that comes about with the use of this new form of communication
(Huang 1996, pg.864).  He characterizes the form of communication on the internet as timeless and omnipresent.  That is, everything can be stored and thus held onto in a lasting fashion.  With the accumulation of a large body of information the fantasy of omniscience becomes possible.

Polarization and extreme vacillation in the appraisal of one’s self and others seems to be an important aspect of relationships on the internet (Hoekstra 1999, Seemann et al. 1999).  According to Young (1996a), the standard for email is the quickly written word without eye-contact, the nuances of intonation, or the immediate possibility for noting and correcting misunderstandings.  Communication via email intensifies the problems already cited in the literature about psychotherapy conducted by telephone; the idea of "visual deprivation", the absence of nonverbal cues and body language that are the result of the contact being so limited, are discussed there (Chiles 1974, Kaplan 1997, Rotchild 1997).

One of the most striking features of email forums and letters is that people can experience almost no impediment to expressing themselves - for good or ill. They can say something which they would be very unlikely to say on the phone or write in a letter, largely, I think, because it all feels as if it its happening in the head. You do not even have the other person’s voice cues; no piece of paper, envelope, stamp or trip to the post is required. Cyberspace has a fantasy quality. As a result, people say the most intimate thing and the most horrid things with considerable ease

(Young 1996a, pg.2).  Holland (1995) has coined the term "Internet Regression" for this phenomenon.

According to Young, the internet is especially attractive for the shy and schizoid people who separate the emotional aspects from the intellectual and imaginative.  In particular it is especially attractive for "people with grandiosity in their make-up" (Young 1996b, pg.4).  A very fragile self can express himself: On the one hand, with it one can hope to attain a high degree of authenticity and intimacy, while on the other hand maintaining control over what is revealed and what remains hidden without lying.  Young sees the problems of communication on the internet as being primarily due to the lack of a physical presence (Young 1996c).  The absence of a face to face presence has the effect, according to Young, of the sense of containment being associated with the relationship, and is the basis for a dramatic distancing, idealization, and devaluation which often overtakes relationships on the internet.

With this in mind, much of the alarming contributions made by participants in suicide fora become much less dramatic.  The drama seen in contributions to the fora and chat rooms is not a clear sign that the participant has any intention of acting on his suicidal ideas.

Suicidality of Children and Adolescents

According to the most recent figures from the Federal Office of Statistics (1999) for the time period of 1996-1999, between 321 and 345 children and adolescents took their own lives per annum:

Year

under 15 (y.o.)

under 20 (y.o.)

 

total

male

female

total

male

female

1999

35

26

9

286

230

56

1998

50

34

16

295

224

71

1997

36

28

8

298

237

61

1996

51

36

15

276

224

52

The numbers are very conservative.  The actual numbers could easily be at least 25% higher, drug-related deaths being a particular category that could account for suicides that are not being tabulated as such.  Suicide is the second most common cause of death of young people (accidents being the most common cause).

The number of suicide attempts in this age group can only be estimated since the relevant data is kept confidential by law.  We estimate the number of attempts by males to be roughly 10 to 15 times the number of deaths observed in that category and estimate the attempts by females to be 40 times the number of deaths observed.  The number of suicide attempts in these age groups can be conservatively estimated to be 5000 to 6000 annually (in the literature one can find estimates of up to14,000 annually).  While one does not clearly observe an increase in the number of suicides in this age group over the past few years, the monitoring by the "WHO-Europe Multicentre-Study on Parasuicide" reveals that there is an increase in the frequency of suicide attempts.  The rate of recidivism for suicide attempts is in the range of 20 to 30%, of which roughly 10% die within 3 years of the initial attempt.  Based on studies, one can calculate that 15 to 30% of adolescents contemplate suicide or their own death at least occasionally.

Although suicides and suicide attempts are frequently correlated with mental illness, one should remember that (even in the presence of a manifest psychopathology) all the typical, developmental phase, intra psychic, familial, and psychosocial conflicts that contribute to juvenile suicidality are secondary to the primary problem of that age, namely the need to become independent of the parents and to develop one’s own, adult identity (Berger 1999).  The emerging, adult personality is inherently involved in the dynamics of a suicidal crisis.  The external motives (bad self-image, disappointments, conflicts with parents, partner or friends) are but

under the assumption of having a threatening, decompensation significance if the adolescent has a sense of being essentially unworthy for a long time, a pronounced, inner anxiety, is compelled to remain emotionally dependent on the parents, feels himself to be unloved and unlovable, or sexually not normal and possibly crazy.

(Berger 1999, pg.40).  As a rule, suicidal adolescents are difficult to reach, either by their parents or professionals, and they show a low rate of compliance.  Berger makes an observation concerning adolescents and suicidality that we have also found in our clinical practice with adults: 

Undoubtedly it is difficult for adolescents to participate in a therapeutic relationship.  In particular adolescents resist having their suicidality as a symptom of an intra psychic conflict resolution taken away.  Just as anorexia can be guarded like a jewel, so it can be with suicidality.  Both phenomena serve as subjectively valuable attainments, and can be considered strategies in the process of developing into adults or as a means of fighting the transition to adulthood.  It follows that a suicidal adolescent will often sabotage, rather than establish, a therapeutic relationship.  He does not want to understand his suffering, rather he wants to end his life

(Berger 1999, pg.59.  Also see Laufer 1995).  What this means is that the adolescent does not want to be saved, rather he wants to be taken seriously and for his suicidality to be understood.  He wants to keep the option of suicide open.  This is often hard for parents, friends, teachers, and professional helpers to accept.  We can establish from our ambulant psychotherapy with acutely suicidal patients that a therapeutic relationship often first forms when the therapist accepts the patient’s suicidality.  This might be the basis for the fascination many juveniles have with communicating through the suicide fora:  Here they find- without having to reveal anything- an acceptance and understanding of their experience that they cannot expect in real life.  In real life they are afraid of misunderstanding, stigmatization, hospitalization, and monitoring.

Opportunities and Dangers

The fora and chat rooms on the internet can provide adolescents an opportunity to anonymously express their despair, hopelessness and feelings of being trapped, and to get a reaction under circumstances when they feel they cannot confide in people physically close to them or do not wish to meet face to face with professional counselors such as doctors and psychologists.  This can provide emotional relief and with much luck initiate the process of locating and having long-term, direct, personal contact with a therapist.

It is also supposed that adolescents who participate in fora discussions, who are not reachable by professional assistance and who are discussing suicidality, will be identified and assisted due to other problems (drugs, high risk behavior, violence, etc.). As to the idea that people who do not seek out face-to-face counseling can be reached through the peculiarities of communicating via the internet (see above), this is attested to by the experience of people who offer counseling via the internet (the Samaritans, ministers, etc.). Whether and how the participation in suicide fora could be transferred to sources of professional help is wholly unknown at this time. [Given the availability of people on the net such as the Samaritans, it might be useful to give more thought as to why an individual might prefer participating in the suicide fora over interacting with the Samaritans. ]

Also, nothing is clearly known concerning the dangers of these discussion fora. It is not possible to make general assumptions based on individual cases. Suicide pacts have been known to happen since before the internet was invented and in daily clinical experience they do not take place over the internet. What the internet offers in this case is a greater number of possibilities. Due to the wide coverage of the joint suicide of the two young people in Norway, one can expect copycat suicide pacts to take place, though not an overall increase in the number of pacts. That the participants in these fora are known to commit suicide demonstrates that they are, in the long run, suicidal. Whether they would still take their own lives had they not participated in the fora is unknown - but it is not unlikely. We also do not know how many participants in these discussion fora eventually take their lives, though it would appear that many do not do so. We only know a little about the intra psychic function of participating in very detailed discussions of suicide methods for the participant (that is, the potential meaning of these exchanges as a solution of and mastery over inner conflicts is unknown). As an example, we know from ordinary clinical experience that many who are suicidal who make arrangements and acquire the means to kill themselves survive for years, and the direct exchange of extensive suicide fantasies, plans, and urges can have a clear, unburdening effect. It is also striking, that the method questions in the fora that are discussed continue to be discussed even in the presence of stable web sites that offer detailed instructions concerning the topic. Nevertheless, a danger exists for many adolescents. The scientifically unproven conjecture is that people, especially adolescents, who have manifest psychological problems (e.g. schizoid or borderline personalities) will withdraw from real life social relationships and become addicted to the internet.

As participation in fora discussion is not necessary to obtain information about suicide methodology, it can be conjectured that the methodology discussions and announcements of one's pending suicide are an expression of an ambivalence that is inherent to their suicidality; it is not so much that they wish to die so much as they do not wish to carry on with their present lives. Nevertheless, suicidality is still being conveyed! The act of communicating is in itself a form of connection to life. And here lies a danger which the forum master under-rates; preoccupied with the ideology of the right of people to end their own lives, they fail to notice that most posts express the conscious or the unconscious wish to survive. [One may well argue that the act of communicating, in and of itself, implies that one has not totally turned one's back to life. But since the premise of certain fora is that it is up to the individual to decide for himself whether his life should be continued, it does not necessarily follow that a forum master fails to recognize the posters' ambivalence concerning death when he does not obviously react to a wish, expressed at whatever level, to survive. One might consider the possibility that the forum master understands a poster's ambivalence, but, believing the responsibility for making the ultimate decision rests with the poster, does not try to second guess him or to do anything that could be construed as an attempt to intervene.] The professionalism of the forum masters is hence problematic, as is the unknown motivation they have for running such fora.[To the best of my knowledge, only one professional in the mental health field has made any attempt to contact the archivist who runs the a.s.h. web site. If there is a genuine interest to understand the people who participate in suicide fora and the people who maintain them, it would be interesting to know the extent to which any effort has been made to directly communicate with them on this matter. ] The failure to acknowledge their conscious or unconscious fantasies of being saved in the fora discussions could result in the participant feeling a greater sense of disappointment and thus lead to suicidal actions [Possibly this is so, though it seems to be a conjecture that would be appropriate to include in the section above that discusses unproven assumptions].

To estimate the dangers involved, a close observation and examination of the discussions in the fora is desirable. To determine the potential for danger in a forum, one should especially analyze the answers that follow a posting of suicidal intentions.

In the medical/psychological technical literature there is essentially no research concerning internet communication and suicidality to be found. Three papers call attention to the dangers, but they are short, general, and unspecific (Adekola et all 1999, Dobson, 1999, Mehlum 2000). In addition, there is an extensive statement of the problem by Baume (1997), a textual analysis of the posts in the newsgroup "alt.suicide.holiday" (Fekete 2001), a paper by Janson et al. (2001) concerning internet observed suicide attempts (which we could not obtain), and a report by us concerning email communication in the therapy of suicidal patients (in press). To the best of our knowledge, the percentage of visitors to suicide fora who take their own lives or attempt suicide has not been studied, nor has it been studied whether participation in the fora motivates one to suicide, or has deterred suicide, or to what extent the suicide or suicide attempts have occurred without participation in these fora. A precise examination would serve as the foundation for a sound appraisal and judgment and would be desirable.

Answers to the Questions of the BMBFS

Ques. 1: Do you have experience with juveniles who are involved with suicide fora, and what do you estimate the potential for damage to be?

We do not have direct experience with juveniles who are involved with suicide fora. We have over 11 years clinical experience in ambulatory psychotherapy and psychiatric work with actively suicidal people who are 16-17 years old. In the past 7 years we have observed an extensive presence of the internet. In this context we have acquired experience with email correspondence with suicidal patients and have scientifically examined it. In addition to our extensive online services, we host the site for the European Network for Suicidology (ENS). For the past several years we have regularly searched the net to see what is available that has to do with suicide.

For an appraisal of the dangers, please see the preamble above.

Ques. 2: When technical details are being discussed in these fora, do you think it is simply a reflection of interest in this information or do you think it is an expression of the wish to have somebody intervene in their death wish? Do you have any experience concerning this possibility?

As yet our experience is that contributions from professionals are rejected in the fora. Reactions to attempts to intervene on an external death wish can be summed up by the following comment: "Leave us alone, I don't want to destroy myself." Our impression is that in such a situation professional intervention shall be rejected and could even be counterproductive, as it is interpreted as coming from someone who wants to save the posters and who does not acknowledge that suicidality is a part of their personality. Nonetheless, we would not wish to exclude the possibility of their being professional interventions that likely occur only with the consent of the forum masters. [If it becomes known that participation in a certain forum means being confronted with professional help, those people who do not want such help will likely stop participating, and will likely find another forum in which to participate. If they wanted such help, they would probably go find a source of professional help either online or offline.]

Ques. 3: What possibilities do you see for influencing "misguided" people who actively promote suicide, who portray it as "the cleanest solution" or as a "unique, consistent attitude", who offer themselves as a "companion in the final hours", who provide detailed guidance on suicide methods, or who give directions on how to acquire implements of suicide (e.g., weapons, drugs)?

In these cases, pressure should be exerted on the ISP (including foreign ISPs) to close fora and web sites on which such activity takes place. In individual cases this will be possible. Certainly there exists the danger that the forum master will move to another ISP, one who refuses to shut him down. [Another possibility is that the people who run the sites found offensive will go underground.]Whether the application of criminal law would be possible is not known to us.

Ques. 4: What do you think of the possibility of regularly sending (posting) in the fora warnings about offers to advise [people on how to suicide], and possibly even automating this activity?

I do not think that such a step would be effective. It is likely that such posts would be found by the participants to be disturbing, meddlesome, and as evidence that their own posts are not being taken seriously.

Ques. 5: What possibilities do you see for influencing the people who run such fora? Can this be done on a "good-will" basis, or do you know of any legal means?

The attempt to influence the fora masters in goodwill is certainly meaningful. It also seems meaningful to me to stimulate these people to provide references to [professional] help in the fora themselves. That would be more effective than unsolicited posts from a third party. One possibility might be that, in agreement with the forum master, a professional side-chat with posters be enabled when in a professional's judgment such people are acutely at risk of committing suicide. [Given the nature of communication on the internet as outlined in the preamble above, it would be interesting to learn how a professional would decide that a given poster is acutely at risk of committing suicide and is not engaging in hyperbole. Another point of this proposal to consider is this: If a person participates in a forum that is pro-choice on the question of suicide and is not instead calling a suicide prevention hotline, would it not be reasonable to infer that the poster in question is not interested in professional intervention?]An agreement with the fora masters should certainly take care so as to not give their collaboration the appearance of being a "support of suicide prevention". [Given that the overall intent of such side-chats is clearly that of suicide prevention/intervention, that would be a difficult appearance to avoid].We do not know about legal means. In any case, fora in which suicide is promoted, where juveniles are pressured to commit suicide and help in acquiring means is promised, should be closed by the people who run them. Perhaps it would be possible to influence the sites' ISPs, by providing sufficient proof, to close such sites. Certainly the links to these fora should be removed from the results provided by search engines (e.g., Yahoo and others).

Ques. 6: What do you estimate the effect to be of official warnings about the potential danger of such fora? Is it possible they could prompt the interest of more juveniles? In view of the media reports, would they obsolete?

Unfortunately, the sensationalist media reports have defined the general view of these fora. It is my estimate that official warnings would only give more weight to the fora and would not deter those who seek them out. People with suicidal ideation certainly would not be deterred thereby from seeking such fora, though perhaps juveniles who are curious about these fora would find them sooner. It would be better to warn against those in the media who present suicidality and the suicide of juveniles in a sensationalist manner.

Ques. 7&8: What form of warning and through which institutions (if applicable) would warnings about the potential dangers and/or participation in such fora do you think would be effective? In your view, which prevention strategies should the juvenile welfare service follow?

In our opinion, preventative efforts should not consist of warnings about the fora but rather in the promotion of public awareness and the lifting away of the societal taboo about suicide and suicidality. It is our opinion that juveniles already have suicidal thoughts when they seek out suicide fora and do not acquire them for the first time there. Clearing up this issue involves acknowledging that it is not shameful to have such thoughts, and addressing the questions of how to deal with them, how to recognize them in others, and how and where one may help. It is our estimate that the inquiry concerning the suicide fora and the current media coverage of them is a symptom of the helplessness of society when it comes to handling the suicidality of its members, and does not address the cause of suicidality.

My view is that suicide fora with specialized information should be observed quite closely. the attention is not to be directed so much toward the suicidal expressions of the juveniles, but rather toward the answers that they receive. In my view, this is because the answers determine the dangerousness of a forum. The development and funding of a project to scientifically study the effects of suicide fora and to develop the criteria for determining their dangers and to determine their role in preventing suicide would be meaningful.

Juveniles, parents, and potential mentors such as teachers and specialists in juvenile welfare, should learn the warning signs and receive instruction as to how to talk with juveniles about suicidality. It is not without reason that WHO puts the breaking of the taboo over suicidality and "awareness" at the top of its list of suicide preventative measures.


References

Alao AO, Yolles JC, Armemta W (1999) Cybersuicide: The Internet and Suicide. Am J Psychiatrie 156:11: 1836-1837

Baume P, Cantor CH, Rolfe A (1997) Cybersuicide: The Role of Interactive Suicide Notes on the Internet. Crisis 18/2: 73-79

Berger M (1999) Zur Suizidalität in der Adoleszenz. In: Fiedler G, Lindner R (Ed) So hab ich doch was in mir, das Gefahr bringt. Perspektiven suizidalen Erlebens, Göttingen: Vandenhoeck & Rupprecht, 1999

Chiles JA (1974) A Practical Therapeutic Use of the Telephone. Am J. Psychiatry 131: 1030 ­ 1031.

Dobson, R. (1999) Internet Sites May Encourage Suicide. British Medical Journal 319: 337

Fekete S (2001) The Internet - Data on Suicide, Depression and Anxiety. In.: O. Grad (Ed.): Suicide Risk and Protective Factors in the New Millenium, Ljubljana: Cankarjev dom, 2001

Holland NN (1995) The Internet Regression.
Online Dokument: http://human-nature.com/free-associations/holland.html

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Kaplan EH (1997) Telepsychotherapy. Psychotherapy by Telephone, Videophone and Computer Videoconferencing. The Journal of Psychotherapy Practice and Research 6: 227 ­ 237

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Prass S (2000) Suizid-Foren im Internet. Eine neue Kultgefahr?
Online Dokument: http://www.religio.de/dialog/300/22_16-19.htm

Mehlum L (2001a) The Internet and Suicide Prevention. Crisis, 21/4: 186 - 188

Mehlum L (2001b) The Internet and Suicide Prevention. In.: O. Grad (Ed.): Suicide Risk and Protective Factors in the New Millenium, Ljubljana: Cankarjev dom, 2001

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Online Dokument: http://www.psychomedia.it/pm/telecomm/telematic/young2.htm

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Online Dokument: http://human-nature.com/rmyoung/papers/paper17h.html

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