Intervenţia în criza suicidară: o abordare bazată pe internet

Introduction

The intervention in suicide crisis in an important part for any organization or institution focused on suicide prevention. Demanding and necessary, it requires the use of well-prepared resources, a long-term planning, and early and adapted response. The intervention in suicide crisis represents a means, a tool and an objective, at the same time.

Each suicide prevention organization, public or private, can provide different ways for addressing the intervention in suicide crisis. Traditional or modern approaches are used concurrently, based on the needs of addressees and on the organization’s resources. On-site real-time crisis intervention, crisis intervention lines or internet-based intervention are means and ways of support.

The wide spread use of internet and the increased community access have created new opportunities for suicide prevention organization in order to address the suicide crisis. Directly or complementary used, the intervention through the internet in the suicide crisis saves million of lives every minute, hour, day, month and year. We shall consider this as a gold medal in contrast to a black medal represented by the same use of the internet to promote the suicidal behavior and the proliferation of the suicidal thoughts. Since 2012, the importance of online prevention strategies in connection with the concern about websites that both promote and encourage suicidal activity has been underlined in different published reviews^(1,2). The same idea was sustained in another research which underlines that the information available online differs in quality, and some websites even encourage suicide, but numerous professional online suicide and mental health help sites and media have registered encouraging results in crisis intervention and suicide prevention^(3,4). The both side of the medal were recently underlined. The connection between social media and suicide, on one hand, and the potential of social media as a positive tool for well-being, on the other hand, were revealed by Popoola et al⁽⁵⁾.

Internet accessibility

In 2011, based on different reports^(3,6), there were 2.1 billion internet users worldwide, and around 58% of internet users reported searching for health-related information for themselves. In 2020, the number of internet users increased and the need for help through the internet has risen substantially⁽⁶⁾. A distribution of the total number of internet user is reflected in Table 1 (or visual distribution in Figure 1).
 

Study case: Romania

In case of Romania, the internet use represents 2% at the European level. The penetration for internet at the national level is 73.80%, with a total internet users of 14,387,477 from a total population of 19,483,360 people⁽⁷⁾. In this context, the addressability for suicide prevention and suicide intervention on the internet basis is not just legitimate, but also necessary. Based on the mission and objective, the Romanian Alliance for Suicide Prevention (ARPS)⁽⁸⁾ – a non-governmental organization (NGO) focused on suicide prevention – carries out a long activity with efficient results in suicide crisis intervention. The full activity of the ARPS is reflected through its website⁽⁸⁾ and the main interventions in suicide crisis and suicide prevention are the objective of others researches and articles. This article aims at presenting a short framework of the activity developed and sustained by ARPS for intervention in the suicide crisis, with consideration to internet-based approach as an alternative means for suicide crisis intervention. This article is a follow-up and an extension of the speech presented by the authors on the Romanian Day for Suicide Prevention (ZNPS), 6^th edition, on 7 November 2020. ZNPS was proposed and created by ARPS as the Romanian National Day for Suicide Prevention, in 2014, with the aim and mission of suicide prevention awareness.

The approach of suicide crisis intervention based on the internet was used by ARPS as an alternative framework for intervention in suicide crisis and for suicide prevention. The development was in concordance with the internet evolution and addressability. Currently, the situation is marked by the global COVID-19 pandemic. The lockdown imposed a change in the addressability and usage of the internet for suicide prevention and suicide crisis intervention. This interventional tool has become more interesting and useful for people with a suicidal risk.

APRS tool for suicide crisis intervention through the internet is marked by a shift and a change generated by the lockdown during the pandemic and the following months. As a general remark, the number of contacts suddenly increased and people started to search for this way. With regard to addressing the suicide crisis via the internet, ARPS noted a change in both the content of information related to the suicide crisis and the number of requests.

As a usual way of addressing the suicide prevention organization via internet, there can be mentioned: (1) contact via e-mail requests, (2) chat messaging, (3) internet contact via telemedicine/teletherapy. In case of ARPS, the means of intervention in suicide crisis is the contact via e-mail. Other tools are considered, but there are currently not implemented. Worth mentioning is the fact that this e-mail contact is not the main way of suicide crisis intervention, but an alternative way for contact in case of specific target population at risk for suicide. The contact could be realized simply by e-mail at sos@antisuicid.ro or by contact from the webpage⁽⁹⁾, as presented in Figure 2. The formular and the e-mail can be filled in and sent any time. This is considered an added value for people at risk for suicide, due to the fact that the ARPS crisis line is available at the number 0800 801 200, between 7:00 PM and 7:00 AM every day.
 

For accuracy and professional reasons, starting with 2020, the contact for website and consequently for e-mail was changed with the extension .ro instead of .com as previously used. This change does not affect the process of contact. It is important to mention the fact that the contact does not provide a real-time answer as it is seen in chat, messenger or any Chatbot. But it offers a way to make a contact and have an answer given by a real person, a volunteer or a specialist with specific training for crisis intervention and suicidal intervention. A team of volunteers are answering these e-mails based on organizational planification and requests.

The persons who address this way of contact are: (1) people at risk for suicide or in suicide crisis, (2) people who want more anonymity, (3) people who need counseling (4) people/caregivers who need information and counseling. Beginning with the lockdown and as a consequence of reduced medical access, more people with impossibility to access medical services started to e-mail ARPS, reporting suicidal thoughts and asking for help. In this context, sos@antisuicid.ro became from an alternative way of support a real help for real people in needs, people in isolation, people at risk for suicide, and for people who lost contact with their mental health specialist. For instance, in the situation imposed by the celebration of the National Day for Mental Health, in October 2020, about 60 e-mails were received in 48 hours. The senders were both people in need for mental health support, with suicidal thoughts, ideation and intention, or caregivers seeking support and help for their family members or friends.

A specific group who address ARPS via e-mail are people living outside the country’s borders or friends and family members of people at risk for suicide living in Romania. The ARPS crisis line is free of charge, but is restricted to calls only from Romania. The people living outside the country are unable to call this line, thus they prefer to e-mail ARS, asking for support. They also report that they are able to call the crisis lines from the country where they reside, but they prefer to express themselves in their native language, because it is difficult to express their suicidal thoughts in another language. Also, friends and family members of people living in Romania and who express their suicidal ideation and intention through social media, Facebook, WhatsApp or by private conversations, send e-mails to ARPS in the need of local intervention or at least for counseling what to do further. The need for care and information is real and is beyond the way of communication. There is no barrier in communication when the support is needed and the way of communication outperforms any restrictions. Only the information and support count.

The security of the data sent by e-mail to ARPS is ensured due to encrypted data transmission and the anonymity of the senders is fully accepted and treated with responsibility. Sometimes, senders use pseudonyms in an attempt to protect themselves, but other times they provide data with full name and contact details, as an attempt to receive support and treat themselves normally. Sometimes, they just send questions marks to check the services and, based on the volunteer answers, they come with follow-up and more details. In the months post-lockdown, due to the pandemic context, the feeling of isolation and insecurity led to an increased number of e-mails and requests.

Due to the organization policy and confidentiality, the e-mail contents could not be provided as examples either for general public, or for specialist. However, a profile of those who address ARPS through e-mails and internet can be shaped. This includes: (1) people who write outside the Romanian border, (2) people who need help, but the feelings of insecurity and anxiety are high, (3) the emotions are too high and don’t enable a voice conversation at the telephone, (4) the addressees need help, but they are just too afraid or ashamed to ask directly, (5) recently, the addressees lost contact with the medical or specialized care and need support,
(6) caregivers, friends or family are asking for information for someone with suicidal ideation or intention and don’t want to use the voice crisis line, as this might be needed by people who can call, (7) the addressees need time to perceive and formulate their thoughts.

Conclusions

The support offered for people in need in case of suicide crisis can vary in intensity and regarding the means and tools. As every life counts, and  since suicide is the only death that can be prevented,  the non-governmental organizations or the public organizations involved in suicide prevention should not restrict their response only to one means of intervention. Based on their specific resources (human organizational and financial), any means of communication should be treated with hope and importance. The Romanian case of ARPS in addressing the suicide crisis on an internet-based approach is an example and should be used accordingly.