The incidence of suicidal ideation and self-harm behavior increases rapidly during adolescence and represents a period of heightened suicide risk.
SIGNIFICANCE FOR PRACTICING PSYCHIATRISTS
TABLE. Contents of #chatsafe: A young person’s guide for communicating safely online about suicide
Suicide is a leading cause of global mortality in those aged 25 years or younger. It accounts for the largest number of fatalities in females and the third largest number of fatalities in males aged 15 to 19 years relative to other causes of death.1 The incidence of suicidal ideation and self-harm behavior increases rapidly during adolescence and represents a period of heightened suicide risk. Young people who have made a suicide attempt, for example, experience a 10-fold increase in suicide risk compared to the general population and may experience negative psychosocial outcomes that persist into adulthood.2
Role of traditional media
The role of the media has been identified as a critical component in suicide prevention.3 Traditional media’s influence on facilitating suicide “contagion” (ie, imitative behavior) has been well documented. This phenomenon has been linked to the mechanism of suicide contagion, whereby exposure to suicide facilitates suicidal behavior in another. Increases in suicide following exposure to suicide have been documented following celebrity suicides, news reports, and fictional portrayals of suicide, and the young appear particularly susceptible to this effect.
In an effort to mitigate the potential for suicide contagion, several countries have successfully implemented media reporting guidelines to help facilitate the safe reporting of suicide. These guidelines have been largely shaped by evidence that has linked increased rates of suicide to media content including: prominent and ongoing coverage of a suicide death; sensationalized language; stories glorifying the suicide act; and detailed descriptions of the method of suicide. By contrast, content that promotes help-seeking behavior and includes messages of hope and recovery is believed to be protective.
A recent example of the potential confounding effects of the media on youth suicide prevention was demonstrated following the release of the 2017 Netflix series “13 Reasons Why,” which builds up to the graphic suicide of a 17-year-old student over 13 episodes. Suicide attempts that resembled the suicide in the series were reported in several anecdotal media reports throughout the United States. Additionally, an increase in website searches of suicide methods was observed following the broadcast of the series.4 Critics, including the National Association of School Psychologists suggested that the graphic portrayal of suicide without appropriate safeguards and the potential of young people to binge watch episodes in succession may have potentially facilitated incidents of suicide contagion among those with existing vulnerabilities.
By contrast a recent international report found the majority of teenagers who viewed the popular Netflix series found that the issues raised by the show were relevant, increased awareness about factors such as depression and bullying, and promoted conversations about difficult topics among teens and their parents.5
Role of social media
The growing uptake, influence, and diversity of social media platforms pose new opportunities and challenges for the prevention of suicide and self-harm behavior, particularly in young people who are large consumers of new media. A recent study undertaken by Pew Research Center found that 85% of teens regularly access social media sites such as YouTube, Instagram, and Facebook.6 Moreover, the proportion of youth who report being online at a near-constant basis has increased twofold, from 24% in 2014–2015 to 44% in 2018. Similar rates have been reported in young people with mental health diagnoses, with 93% reporting daily use of social media, of which 83% endorse social media for the delivery of online mental health interventions.7
A unique feature of social media-based platforms is the ability for users to generate their own content. For some young people, social media has been shown to reduce a sense of isolation and increase support among peers.8 Certainly, the popularity and accessibility of social media has the potential to remove barriers and facilitate access to information that can help guide young individuals in the management of their own health and wellbeing. These factors may play an important role in a young person’s decision to seek help for suicidal behavior. Indeed, online and social media-based interventions have been shown to be effective and acceptable forms of suicide prevention for young people.9,10
As social media becomes an increasingly integrated part of the lives of the young, concerns regarding privacy, confidentiality, and duty of care in the delivery of social media-based interventions for suicide prevention have been raised. A key priority for providing safe social media-based interventions involves equipping social media platforms with moderators who are sufficiently skilled and competent to deliver appropriate support to those who may be at risk of suicide. This has particularly important implications for those who prefer the delivery of online interventions either instead of or as well as traditional face-to-face support.
Recent data from the US suggest the majority of young people feel comfortable disclosing personal information, such as their psychological and mental health experiences, in online environments.6 These disclosures are accrued by social media platforms as streams of data and have the potential to predict future behavior. To date, several studies have investigated the application of machine learning and artificial intelligence (AI) in the detection of suicide-related content on social media platforms like Twitter. Work currently under way at Orygen, the National Centre of Excellence in Youth Mental Health in Australia, also suggests that the use of AI for safety purposes is acceptable to young people.
Taken together, the acceptability and potential of digital technology in suicide prevention looks promising. Concerns about data ownership, privacy, and the capacity of young people to provide informed consent, however, as well as to understand the risks associated with sharing their personal information on social media, ought to remain a priority among those who work in youth mental health.
#chatsafe: A young person’s guide for communicating safely online about suicide
Although traditional media guidelines have been largely successful in promoting responsible conversation about suicide among journalists and other media professionals, these resources are less likely to be relevant to young people who use social media to communicate about suicide online. For example, existing guidelines for media professionals provide little advice in the way of monitoring social media posts for potentially harmful content and ways to safely respond to someone who may be suicidal online. Despite this, few evidence-based resources are currently available to help guide young people through the process of safe peer-to-peer communication about suicide online.
Our team at Orygen recently developed “#chatsafe: A young person’s guide for communicating safely online about suicide.” The #chatsafe guidelines were developed using the Delphi expert consensus method, which involved two panels of experts: one comprised of Australian youth advocates and the second comprised of international media professionals and suicide prevention experts. The expert panels rated recommendations from the peer-reviewed and grey literature for inclusion in the guidelines. A summary of the core components of the #chatsafe guidelines are shown in the Table. (The full guidelines are freely available for download.11)
Unlike traditional media guidelines, the #chatsafe guidelines provide evidence-based recommendations that are specific to youth and the social media environment. For example, they advise young people to consider the impact of their post on others who may be vulnerable to suicide, provide information on the permanency of the Internet, and include practical information on how to safely operate memorial pages dedicated to honoring the deceased.
Importantly, the #chatsafe guidelines also provide information on how to respond to someone online who may be at risk of suicide. Given recent evidence that shows young people appropriately recognize, interpret, and endorse a desire to respond to those who may be at risk of suicide, the #chatsafe guidelines may offer a practical conduit for suicide prevention (Table).
Recommendations for clinicians/conclusion
Those involved with the care of our digitally expert youth are tasked with the important responsibility of guiding young people through the process of understanding the risks associated with communicating about suicide online. In particular, clinicians who have good awareness of terminology and dynamics associated with online social networks may engage more easily with their younger clients.
Nevertheless, clinicians are unlikely to affect the ubiquitous role that social media plays in the lives of young people, so their efforts should seek to support positive use. Provided the experience using social media is primarily positive, time spent using social media has the potential to operate as a preventive or therapeutic medium that may actually complement traditional therapy. As such, clinicians may benefit from taking clients’ social media use as part of their assessment of social history and suicide risk.
In cases in which clinicians recognize that social media use may be impacting on mental health, discussions can focus on the importance of privacy, respectful communication, thinking carefully prior to posting, and challenging the assumption that content shared on social media is necessarily true. Clinicians should, however, be cautious about accessing patients’ data online without their consent, as such efforts may be viewed unfavorably by patients and may jeopardize the therapeutic alliance.
There is also value in clinicians being aware of their own digital footprint, including the sharing of unprofessional content, engagement with patients in social media environments, or content posted about them by others. Clinicians must also remain mindful of potential boundary violations when writing about clinical experiences and be aware that some patients and families may be skeptical of clinicians writing publically. Nevertheless, appropriate use of social media can be an effective tool for advocacy and education. Some key recommendations include: only write things online that you would say in person, don’t publish content that will only benefit yourself, be mindful that clinicians represent the profession in public communication, and be aware that there is a responsibility to care for a patient’s wellbeing even in online settings.
Ms Hill is a PhD candidate at Orygen, The National Centre of Excellence in Youth Mental Health, Centre for Youth Mental Health, The University of Melbourne; Dr Robinson is a Senior Research Fellow and Head of Suicide Prevention at Orygen; Dr Rice is a Senior Research Fellow and Clinical Psychologist at Orygen.
The authors report no conflicts of interest concerning the subject matter of this article.
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11. Orygen.#chatsafe: a young person’s guide for communicating safely online about suicide. https://www.orygen.org.au/Education-Training/Resources-Training/Resources/Free/Guidelines/chatsafe-A-young-person-s-guide-for-communicatin. Accessed November 20, 2018.