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Offering Support to Suicidal Individualsin an Online Support GroupItzhak Gilat a , Yishai Tobin b & Golan Shahar c da Levinsky College and the Israeli Association for Emotional First Aid(ERAN), Netanya, Israelb Departments of Linguistics and Sociology/Anthropolog, Ben-GurionUniversity of the Negev, Netanya, Israelc Department of Psychology, Ben-Gurion University of the Negev,Israeld Department of Psychiatry, Yale University Medical School, NewHaven, ConnecticutPublished online: 09 Aug 2011.

To cite this article: Itzhak Gilat , Yishai Tobin & Golan Shahar (2011): Offering Support to SuicidalIndividuals in an Online Support Group, Archives of Suicide Research, 15:3, 195-206

To link to this article: http://dx.doi.org/10.1080/13811118.2011.589675

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Offering Support toSuicidal Individuals inan Online Support Group

Itzhak Gilat, Yishai Tobin, and Golan Shahar

The objective of this study was to reveal response strategies to suicidal messages and toexamine the relationships between the messages and types of responses in an onlinesupport group moderated by volunteers within an interpersonal perspective of theAction Theory. This theory posits that individuals actively impact their socialenvironment, which in turn shapes their development and mental health. In the study,120 interactions were analyzed to identify characteristics of the message and strategiesof response. The analysis yielded 8 strategies employed by the volunteers in response tothe suicidal messages. Hypothesized relationships between those strategies and char-acteristics of suicidal messages were found. The results suggest that online supportgroups enable suicidal individuals to generate an environment that provides emotionalsupport, and offer alternatives to the suicidal view.

Keywords Action Theory, internet, suicidal crisis, support groups

Individuals in suicidal crisis undergo anacute psychological experience wherebynegative emotions such as guilt, shame,humiliation, grief, hopelessness, and rageturn into a general experience of unbearablemental pain (Joiner, Kalafat, Draper et al.,2007; Shneidman, 1980, 1996). In spite ofthe desperate wish to escape the pain, manysuicidal individuals exhibit a negative attitudetoward seeking psychological help (Joiner,2005), and about half of those who completedsuicide were not undergoing professional treat-ment at the time of death (Clark & Fawcett,1992; Isometsa, Aro, Henriksson et al., 1994).

An interpersonal perspective of thisdisruptive behavior (Joiner, 1995, 2005;Joiner, Pettit, Walker et al., 2002) posits thatsuicidal individuals are engaged in loops ofnegative feedback that exacerbate the sever-ity of their crisis. Stellrecht, Joiner, andRudd (2006) point out that the suicidal

individuals’ efforts to seek verification fortheir self-view engender frustration and irri-tation among others in their environment.This process, which augments their senseof being a burden, generates the convictionthat nobody can understand or help them.This in turn leads to a negative attitudetoward seeking professional help. Moreover,even when they consult with a therapist, thesame interpersonal processes that occur intheir natural environment also come intoplay in the therapy room, and may impedethe success of their treatment (Shahar, Blatt,Zuroff et al., 2004). Within this interperso-nal perspective, Shahar (2001, 2004, 2006)advanced the Action Theory (AT) as aninterdisciplinary, overarching conceptualframework that highlights the active impactof individuals on their social environment,which in turn impacts their developmentand mental health. As noted by Buss

Archives of Suicide Research, 15:195–206, 2011Copyright # International Academy for Suicide ResearchISSN: 1381-1118 print=1543-6136 onlineDOI: 10.1080/13811118.2011.589675

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(1987), people select social environments,evoke responses from others, and manipu-late other people in ways that elicit eitheradaptive or maladaptive responses.

Applying this interpersonal–AT per-spective to suicide prevention, we soughtto examine exchanges between suicidalmessages and supportive responses in anonline support group. Adopting the con-cept of the traditional face-to-face self-aidgroups, online support groups are guidedby the rationale that social support withinthe context of group processes can be use-ful in coping with psychological distress,including suicidal crisis (Knox, Litts,Talcott et al., 2003). Owing to their uniquefeatures, online support groups, as opposedto face-to-face help, may be particularlysuited to the psychological needs of indivi-duals who experience suicidal crises: Theanonymity may reduce these individuals’inhibitions with regard to self-disclosure,the asynchrony facilitates an almost limitlesspossibility of receiving help, the use of writ-ten language promotes self-disclosure andmay have a therapeutic effect (Pennebaker,1997), and the participants’ shared experienceshelp the suicidal individual discover that his=her experience is part of a known phenom-enon, and this may lead to an improvementin his=her emotional condition.

Empirical evidence shows that onlinesupport groups constitute an attractivesource of help for individuals in suicidalcrisis. This has been demonstrated by thelarger proportion of suicidal individualswho contact online support groups com-pared to those who call telephone hotlines,which are known to have served as one ofthe major sources of suicide prevention inthe community for over 5 decades (Gilat& Shahar, 2007). An indication of the effec-tiveness of online support groups wasreported in a survey among suicidal users,who perceived the forum to be constructiveand suicide preventive (Eichenberg, 2008).

Applying the concepts of the AT inorder to explain this evidence, we suggest

that the features of online support groupsenable individuals in suicidal crisis to gener-ate a supportive environment that may helpthem overcome the maladaptive loops inface-to-face interactions, thereby reducingmental pain and suicidal risk. In the presentstudy we made use of the naturally occurringtextual interactions produced by the parti-cipants in an online support group in orderto examine processes derived from the ATwhereby the characteristics of the suicidalmessages influence the nature of the sup-portive responses. The aims of the studywere twofold: (1) to reveal and characterizethe strategies employed by volunteers inresponse to the suicidal messages; (2) to testhypotheses derived from the AT regardingassociations between the characteristics ofthe suicidal message and the response strate-gies. The data were collected from an onlinesupport group, an asynchronous mode ofcommunication in which a person may posta message to a number of people in areceiver-initiated time delay. Previous stu-dies showed that group processes that occurin face-to-face groups are evident in onlinegroups (Hsiung, 2007; Miller & Gergen,1998; Weinberg, Uken, Schmale et al.,1995). The online support group is operatedby the Israeli Association for EmotionalFirst Aid (ERAN), a volunteer-based com-munity mental health service that offers helpby means of telephone hotlines and theInternet, and is well known to the Israelipublic (Gilat, Lobel, & Gil, 1998). ERANis guided by the principles of caller anon-ymity, volunteer anonymity, assistance witha variety of problems, and high availability.ERAN’s volunteers are given a 6-monthtraining course that includes group sessionsand individual supervision, and is moderatedby professionals. The training seeks toincrease self awareness, provide theoreticalconcepts in suicide prevention and crisisintervention, and develop helping skills forinteractions with individuals in crisis. For adetailed review of the online support group,see Gilat and Shahar (2009).

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While the use of volunteers for thepurpose of crisis intervention has becomecommon in the last decade (Barak, 2007;Lester, 2008), empirical evidence regardingthis issue is scarce. In the present study wefocused on the volunteers’ written responsesto the suicidal messages.

The study comprised two phases. In thefirst, we conducted a preliminary studywhereby a qualitative method of semiotic-linguistic text analysis was applied in orderto reveal and characterize the responsestrategies employed by the volunteers. Inthe second phase, we utilized a quantitativeanalytic method to examine the relation-ships between the response strategies andthe characteristics of the suicidal messages.Based on the premise that the suicidalindividuals actively shape the nature of theresponses sent to them by the volunteers’responses (Joiner, 2005; Shahar, 2006), wepredicted that the response strategiesapplied by the responders would be relatedto the characteristics of the suicidal mes-sages that evoked them. Such a relationshipbetween messages and responses was empiri-cally demonstrated in interactions betweensuicidal users and hotlines. Diagle andMishara(1995) found that the two intervention stylesemployed by the volunteers—Rogerian andcognitive-directive style—were related tothe nature of the user’s situation. In viewof the fact that suicidal crisis is characterizedby emotional and cognitive components(Leennars, 1996; Shneidman, 1980), weassumed that the volunteers would adapttheir type of strategy to the specific compo-nent conveyed by the suicidal user. Morespecifically, the following specific associa-tions were hypothesized:

1. Suicidal messages with components ofcognitive constriction (irreversibility andemptiness) are related to the use of cogni-tive change inducement and persuasion.

2. Suicidal messages with a componentof frustrated attachment needs (acuteloneliness) are related to the use of

emotional support and offering groupsupport.

3. Suicidal messages with a component ofself-criticism or narcissistic injury are res-ponded to by a strategy of empowerment.

4. Suicidal messages with a component ofhelplessness (loss of control, loss ofenergy, and emotional flooding) are res-ponded to by emotion-focused strategies(emotional support and group support).

5. Suicidal messages with a component ofhigh suicide risk are responded to bystrategies of persuasion.

METHOD

Nature of the Data

The data consisted of 120 suicidal inter-actions (58 females, 38 males, and 25 whosegender was unknown) retrieved from theasynchronous support group (‘‘forum’’)operated by ERAN. Each interaction con-sisted of a suicidal message posted to theforum and a response sent by a volunteer.The sample was randomly selected fromamong a sum total of 252 suicidal messagessent to the forum over the course of theyear 2006. The criterion for defining aninteraction as suicidal was the explicitexpression of a wish for death or self-harm.As regards the volunteers, 68% werefemales, the mean age was 52 (SD¼ 10.6),and all had at least 1 year’s experience work-ing in the forum. The interactions occurrednaturally in the forum, and both users andvolunteers were unaware of the purposeof the study. The latter was approved bythe ethics committee of the Departmentof Psychology at Ben-Gurion University.

INSTRUMENTS AND ANALYSIS

Analysis of the Suicidal Messages

Three aspects of the suicidal messagewere measured: mental pain, cognitive

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attribution, and level of suicidal risk. Mentalpain is viewed as a major component of thesubjective experience in a suicidal crisis(Shneidman, 1980). Expressions of mentalpain were reported as a differentiatingcharacteristic between suicidal and non-suicidal users who sought help on the Inter-net (Barak & Miron, 2005). We used theoperationalization suggested by Orbach,Mikulincer, Sirota et al. (2003), whodeveloped a scale to measure mental pain,and found nine categories in a factor analy-sis. We first examined the applicability ofthis scale to suicidal messages in an onlinesupport group. Two trained psychologistswere presented with the definitions of thecategories (Orbach, Mikulincer, Sirota et al.2003) and were requested to indicatewhether these categories could all be ident-ified in a random sample of 30 suicidalmessages retrieved from the full sample of120. The psychologists were also requestedto assess whether additional categories ofmental pain could be identified in the suici-dal messages. In view of the dichotomousnature of the measure, Kappa coefficientswere used to evaluate inter-rater reliability.The coefficients ranged from .72 to .94for the nine factors. In addition, the analysisyielded two categories of mental pain thatwere not included in the Orbach et al.(2003) study. The first was labeled ‘‘AcuteLoneliness’’ and reflected the feeling ofbeing socially isolated and emotionally notunderstood. The second was labeled ‘‘Lossof Energy’’ and reflected the subjectiveexperience of a depletion of internal forces.The two categories were added to our mea-sure of mental pain. The frequency of theoccurrence of the nine categories of mentalpain in the entire sample of suicidal mes-sages revealed that four of the original ninecategories reported by Orbach, Mikulincer,Sirota et al. (2003) were identified in fewerthan 5% of the messages. The four cate-gories, namely, Freezing, Self-Estrangement,Confusion, and Social Distancing, wereexcluded from further analysis. Thus, the

final list that was applied in the analysisconsisted of seven categories: five identifiedby Orbach, Mikulincer, Sirota et al. (2003),namely, Irreversibility, Loss of Control, Nar-cissistic Wounds, Emotional Flooding, andEmptiness, and two categories that emergedfrom the analysis of the data in the presentstudy, namely, Acute Loneliness and Lossof Energy. In order to measure mental painin the entire sample of messages, two psy-chologists who had not participated in thefirst phase of the analysis were presentedwith the definitions of the seven categoriesand were asked to read the 120 suicidal mes-sages and to determine which categories werepresent in each message. Reliability was mea-sured by Kappa coefficient values that ran-ged from .78 to .94 for the seven categories.

The two additional categories that wereused to measure the messages are CognitiveAttribution and Level of Suicidal Risk. Wechose Cognitive Attribution to measure thecognitive constriction aspect of the suicidalmessage since it is viewed as a major sourceof suicidal crisis (Shneidman, 1980). It wasmeasured by the presence or absence ofspecific attributions by the suicidal individ-ual (such as humiliation by others, job loss)to the suicidal thoughts or intentions.

The behavioral aspect was measured bythe level of suicidal risk. A modified versionof a scale used by King, Nurcombe,Bickman et al. (2003) to evaluate the suici-dal risk of hotline callers was applied tothe online support group. The 11 itemsemployed by King, Nurcombe, Bickmanet al. (2003) to evaluate suicidal ideationand suicidal urgency were categorized intothree levels of risk, based on standards forthe assessment of suicidal risk among callersto suicide prevention lifelines (Joiner Kala-fat, Draper et al., 2007): (1) suicidalthoughts; (2) suicidal intentions with nospecific plan and=or mention of past suicideattempts; and (3) a specific plan and=or sui-cidal act. To measure the suicidal risk ofeach message, the two raters were requestedto assign it to one of the three levels.

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The reliability of the cognitive andbehavioral aspects was measured by theagreement between the two raters who ana-lyzed the 120 suicidal messages. Kappacoefficients yielded a value of .91 for thecognitive attribution and a value of .89for the suicidal risk.

The list of characteristics used toanalyze the suicidal messages, with theirdefinitions and exemplifying quotations, ispresented in Table 1. Since the categoriesof mental pain are not mutually exclusive,the percentages in the table do not addup to 100.

Analysis of the Responses

The first phase of the study set out toidentify and characterize the strategiesemployed by the trained volunteers inresponse to the suicidal messages. The dataconsisted of the volunteers’ responses to 60suicidal messages randomly retrieved fromthe full sample of 120. The decision to use60 messages was based on the assumptionthat the repertoire of strategies employedby the users would be fairly representativeof a sample of 60 interactions. To analyzethe responses, we employed a semioticapproach to linguistic analysis. Thisapproach is based on the premise that thereis a causal connection between the non-random distribution of the language in aspoken discourse or written text and theextra-linguistic message of that discourse=text. (For a detailed review, see Tobin,1990, 1994.) In order to identify the strate-gies of response, we utilized the methodof ‘‘word systems’’ (Aphek & Tobin, 1988,1989), which is based on the recurrent useof words with a common linguistic denomi-nator in a discourse=text. These words maybe viewed as a mechanism that creates com-pactness of the discourse=text and capturesits essence. The semiotic analysis wasapplied by Aphek and Tobin (1989) toidentify and characterize strategies of

communication in an interpersonaldiscourse that shares some similarities withinteractions of help-seeking.

Applying the method of ‘‘word sys-tems,’’ the two psychologists were eachrequested to read 30 suicidal messages andresponses (out of the 120 that were exam-ined), and to identify the types of strategiesemployed by the responders. The instruc-tion given to the psychologists to read thesuicidal message and not only the responsewas based on the assumption that the con-text of the entire interaction was useful forthe valid identification of the response strat-egy. The analysis, which was conductedindependently, was guided by identifyingwords or sentences with a common linguis-tic denominator that engendered an essenceof a response strategy to a suicidal message.Upon completion of the analysis, the psy-chologists discussed their results and agreedupon a common list of eight strategy types.

In order to examine the researchhypotheses with regard to the strategies,the responses in the sample were all codedaccording to the final list of strategies. Twopsychologists who had not participated inthe preliminary study on the response stra-tegies were presented with the definitionsof the strategies and were asked to readthe suicidal messages and the responsesand determine which strategies were usedby the responders for each response.Reliability was measured by Kappa coef-ficient values that ranged from .74 to .92for the eight strategies.

RESULTS

Response Strategies to Suicidal Messages

The qualitative analysis yielded eightstrategies of response employed by thevolunteers. The definitions of the strategies,along with exemplifying quotations as wellas the frequency of each strategy, are pre-sented in Table 2. The strategies are not

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TABLE1.CharacteristicsofSuicidalMessages—

DefinitionsandFrequencies(n

¼120)

Category

Definition

Examples

Frequency

Percentage

A.MentalPain

Loss

ofcontrol

Uncontrollability,unpredictability,helplessness,

ambiguity

‘‘Ifeeltheearthshakingbeneath

myfeet’’

49

41

Acute

loneliness

Hurt-related

feelings

such

asrejectionand

abandonment

‘‘Iam

lonelyin

thisdarkworld’’

37

31

Emptiness

Theloss

ofpersonalmeaning

‘‘Ican’tstandmyem

ptiness,myhearthas

died’’

29

24

Narcissisticwounds

Self-directedfeelings

ofhatredordevaluation

‘‘Ihatemyself,mycharacter,andtheway

I

look’’

24

20

Irreversibility

Mentalpainas

irreversibleandperpetual

‘‘Iwill

never

beableto

enjoylife’’

22

18

Loss

ofenergy

Emptyingoutofinternalforces

‘‘Ihavenopower

toescape,nopower

tofight’’

20

17

Emotionalflooding

Feelingoverwhelmed

byem

otions

‘‘Iam

sick

oftheflashbacks,theattacks,the

flooding’’

17

14

B.Cognitiveattribution

Frustrationofneedsassociated

with

interpersonalrelationships

‘‘Myex-husbandhurtsmeso

much

thatIdon’t

wantto

liveanym

ore!!’’

47

39

Noindicationofattribution

73

61

C.Levelofsuicidalrisk

1.Suicidalthoughts=wishes

‘‘Iwantto

die,to

beerased’’

90

75

2.Suicidalintentions

‘‘Ihavean

insanedriveto

cutmyself’’

24

20

3.Suicidalact=plan

‘‘Ihavejusttaken

anoverdose

ofpills’’

65

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TABLE2.Response

StrategiesAppliedbytheVolunteers

toSuicidalMessagesin

anOnlineSupportgroup(n

¼120)

Typeofstrategy

Definition

Examples

Frequency

Percentage

1.

Emotionalsupport

Offeringem

otionalsupportbyexpressing

affection,em

pathy,agreem

ent,

congratulations

‘‘Iam

sendingyoumylove’’

‘‘Iunderstandthat

youfeelem

pty’’

114

95

2.

Offeringgroupsupport

Invitingthecallerto

join

thegroupandreceive

emotionalsupport

‘‘Youwill

findmanyfriendshere’’

53

44

3.

Empowerment

Identifyinginternalresources,boosting

self-esteem

‘‘Yourwordsareso

strong’’

27

22

4.

Interpretation

Interpretingthepsychologicalorsocialrootof

theproblem

‘‘Youdonotbelievein

yourselfandarenot

awareofit’’

33

27

5.

Cognitivechange

inducement

Offeringalternativewaysofthinking

‘‘Thinkofbeautifuldaysyouhaveexperienced’’

63

52

6.

Persuasion

Presentingargumentsagainstsuicide

‘‘Thedecisionisirreversible’’

43

36

7.

Advising

Offeringadviceorsuggestionforactionsto

alleviate

thesuffering

‘‘Occupyyourselfwiththings

youliketo

do’’

34

28

8.

Referring

Suggestinggettingmore

helpfrom

professional

sources

‘‘Professionaltherapymay

behelpfulforyou’’

17

14

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mutually exclusive so the percentages in thetable do not add up to 100. Since the orig-inal texts were written in Hebrew, thequotations were translated into English bya professional translator. The strategiescan be divided into three categories:emotion-focused, cognitive-focused, andbehavior-focused.

The emotion-focused category was furthersubdivided into two more specific strategies:(1) By means of emotional support, theresponder tried to create a personalemotional bond with the distressed individ-ual. Further analysis revealed several ways inwhich responders provided emotional sup-port. These included a direct expression ofaffection, for example: ‘‘I’m covering you withhugs from my heart;’’ emphatic understanding,for example: ‘‘I feel your emotional storm;’’ greet-ings and prayers for the suicidal individual,for example: ‘‘I pray to God to send you strength;’’use of visual images, predominantly iconssuch as hearts or smileys. (2) By offering groupsupport, the responders invited the suicidalindividual to join the group and use it assource of support: ‘‘I invite you to join us. Weare here to support, encourage and help.’’

The second category included responsesthat were characterized by an abundance ofwords and expressions retrieved from thelinguistic repertoire of cognition such as‘‘thought,’’ ‘‘belief,’’ ‘‘words,’’ ‘‘decision,’’and was titled ‘‘Cognitive-focused.’’ Byemploying this approach, volunteers deliv-ered a message expressing their intentionto change the cognitive outlook of the suici-dal individual. This general category wasfurther subdivided into four more specificstrategies: (1) Empowerment, which aimed tochange the self-perception of the suicidalindividual by raising his=her awareness ofhis=her internal resources. Empoweringresponses were rich in words expressingthe psychological power attributed to thecaller, for example: ‘‘your words are so vivid;’’‘‘you have overcome the diabolical power of anor-exia.’’ An empowering message that wasunique to the online support group consisted

of responses that the suicidal individual hadsent to other suicidal members as an indi-cation of strength: ‘‘Look at what you write toothers; you know how to think positively.’’ (2)The strategy of Interpretation aimed to offera psychological explanation of the sourceof the problem, or to raise the user’s aware-ness of his=her maladaptive ways of copingwith the crisis: ‘‘You chose the easy solution to copewith your problems.’’ (3) Cognitive change induce-ment, which focused on broadening the per-spective of the suicidal individual vis-a-visthe stress-evoking situation by offering analternative meaning, reducing the perceivedthreat, or increasing the salience of the posi-tive aspects of the situation: ‘‘My dear, rightnow you feel all alone, but this situation will not lastforever; the problem is temporary and reversible.’’ (4)Persuasion, which focused on an attempt tochange the attitude of the suicidal individualby presenting logical and rational argumentsagainst suicide: ‘‘Such a decision is irreversible,’’or by presenting general beliefs about thevalue of life: ‘‘Life is too precious to be wasted.’’

The third category was characterized byan instrumental approach and was titled‘‘Behavior-focused.’’ It included responsesthat contained behavioral components pre-senting suggestions or recommendations tothe suicidal individual. Two strategies werederived from this approach: (1) Advising,which offered the suicidal individual practi-cal ways to cope with the crisis, for example:‘‘try to send supportive responses to other membersand you’ll see that it will do you good.’’ (2) Refer-ring, whereby the responder recommendedthat the suicidal individual seek professionalhelp in addition to the support offered bythe group.

The Relationship Between theCharacteristics of the Suicidal Message

and the Response Strategies

Table 3 presents the distribution of theeight strategies for each of the characteris-tics of the suicidal messages. The figures

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in the table show the percentage of messagesin which the strategy was employed whenthe characteristic was present and whenthe characteristic was absent in the message.

The hypotheses regarding specificassociations between the characteristics ofthe messages and the types of responsestrategies were examined by a series ofChi Square tests. Each test examined thestatistical significance of the relationshipbetween the presence of a specific charac-teristic in the suicidal message and the useof a specific response strategy by thevolunteers.

The analyses yielded the following stat-istically significant relationships:

. The strategy of persuasion was used morefrequently in response to suicidalmessages with a component of irreversibility

(46%) as compared to messages withoutthis component (22%), (v2 [df¼ 1]¼ 5.27,p< .05);

. The strategy of persuasion was used morefrequently in response to suicidal messageswith a component of emptiness (43%)as compared to messages without thiscomponent (22%), (v2 [df¼ 1]¼ 4.74,p< .05);

. The strategy of persuasion was used morefrequently in response to messagesexpressing immediate suicidal risk (71%)as compared to lower-risk messages(24%) (v2 [df¼ 1]¼ 7.50, p< .01);

. The strategy of cognitive change inducementwas used more frequently in responseto suicidal messages with a componentof acute loneliness (65%) as compared tomessages without this component(46%), (v2 [df¼ 1]¼ 4.01, p< .05);

TABLE 3. Use of Strategies by Characteristic of the Messages, in Percentages (n¼ 120)

Response strategies�

ES EGS EMP INT CCI PER ADV REF

Loss of control Yes 94 39 20 30 41 26 30 4

No 92 30 22 22 59 27 18 11

Acute loneliness Yes 90 45 13 33 65 28 23 7

No 94 28 25 22 46 27 23 10

Emptiness Yes 89 32 25 32 61 43 29 7

No 93 34 20 23 50 22 21 10

Narcissistic wound Yes 96 32 36 32 50 32 18 9

No 92 34 18 24 53 26 24 9

Irreversibility Yes 100 46 23 27 41 46 41 5

No 91 31 21 25 55 22 19 10

Loss of energy Yes 96 17 30 17 48 17 26 4

No 92 38 19 27 53 29 22 10

Emotional flooding Yes 86 21 29 14 50 43 29 7

No 93 35 20 27 52 25 22 9

Cognitive attribution Yes 93 38 26 21 71 36 14 5

No 92 31 18 27 42 22 27 12

Level of risk Yes 86 43 0 14 14 71 29 0

No 93 33 22 26 54 24 22 10

�Strategies: ES¼Emotional support; OGS¼Offering group support; EMP¼Empowerment; INT¼Interpretation; CCI¼Cognitive change inducement; PER¼Persuasion; ADV¼Advising; REF¼Referring.

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. The strategy of cognitive change inducementwas used more frequently in responseto suicidal messages with a componentof cognitive attribution (71%) as comparedto messages without this component(42%), (v2 [df¼ 1]¼ 9.71, p< .01);

. The strategy of advising was used more fre-quently in response to suicidal messageswith a component of irreversibility (41%)as compared to messages without thiscomponent (19%), (v2 [df¼ 1]¼ 5.10,p< .05);

. The strategy of empowerment was usedmore frequently in response to suicidalmessages with a component of narcissisticwounds (36%) as compared to messageswithout this component (18%), (v2

[df¼ 1]¼ 3.83, p< .05);. The strategy of offering group support was

used more frequently in response tosuicidal messages with a component ofacute loneliness (45%) as compared tomessages without this component(28%), (v2 [df¼ 1]¼ 3.50, p< .05).

DISCUSSION

Two major patterns of strategies aimed toreduce suicidal risk were employed byvolunteers moderating online supportgroup: emotion-focused strategies, whose objec-tive was to establish an emotional bondbetween the suicidal individual and theresponder, and cognitive-focused strategies,which aimed at altering and broadening thenarrow perspective of the suicidal individual.Theoretically, these two response categoriesmay represent appropriate approaches tosuicide prevention since they seem to inter-act with the two psychological states men-tioned as almost universally characteristicof the suicidal mind: an acute feeling of iso-lation and a constricted vision of the world(Shneidman, Farberow, & Litman, 1976).

In view of the paucity of empiricalknowledge regarding the content of interac-tions with individuals in suicidal crisis, the

strategies revealed in this study may makea unique contribution to suicide prevention.Omer and Elitzur (2001) claim that helpersare often helpless in the face of declarationsof intent to commit suicide, and lack guide-lines that can help them communicate withsuicidal individuals. These authors pro-posed a reference text for dissuading poten-tial suicides from realizing their intent.However, their text is hypothetical andbased on theoretical considerations. In thepresent study, we exposed the texts actuallyused by helpers in naturally occurring inter-actions with suicidal individuals.

The volunteers employed emotionallysupportive strategies in response to almostall of the suicidal messages. The interperso-nal AT interpretation of this finding statesthat by virtue of the very decision to posta message on the forum, the suicidal indi-vidual is creating an emotionally supportiveenvironment for him=herself. This maytemporarily alleviate his=her mental paineven if the response is not immediate.

Consistent with our prediction,cognitive-focused strategies were alsorelated to the suicidal message, albeit morespecifically than emotion-focused strate-gies. An analysis of the interactions revealedspecific associations between the character-istics of the suicidal messages and thecognitive response strategies. Cognitivechange inducement was often used inresponse to messages in which the suicidalcrisis resulted from a distorted attributionto external sources such as the humiliatingattitude of other people or adverse financialcircumstances.

Empowerment was used in response tomessages in which the suicidal individualsdescribed a narcissistic wound. Theresponder probably perceived the ambiv-alence expressed by the narcissisticallywounded user and empowered the healthyparts of the latter’s self-view. Persuasionwas often used in response to ‘‘philosophi-cally oriented’’ suicidal messages in whichthe user complained of emptiness and a

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lack of meaning. The response includedrational arguments about the potentialmeaning of life and how to search for it.These findings imply that the suicidalindividual may interact with the onlineenvironment to alleviate the pain not onlyby means of a diffuse process of receivingemotional support. The suicidal messagegenerates cognitive responses that aimmore specifically to alter the cognitivedistortions that led to the suicidal crisis.

Our findings expand the applicabilityof the Action Theory to suicide prevention.Former studies that were derived from theAT reported how suicidal individualsengage in interpersonal processes that elicitthe rejection of others, lead to help nega-tion, and increase the risk of suicidal beha-vior (Joiner, 1995; Stellrecht, Joiner, &Rudd, 2006). Our findings revealed thatthe context of the online support groupmoderated by volunteers affordedconditions that promoted adaptive inter-personal processes and might be used forsuicide prevention.

Some limitations of the study shouldbe noted. First, our findings, whichstemmed from individuals seeking helpfrom an online support group, may notbe generalized to other populations of indi-viduals in suicidal crisis. Second, since wefocused on the initial phase of the interac-tion, i.e., the exchange between the suicidalmessage and the first response, the analysiswas limited as concerns gaining a deeperunderstanding of the entire process thattakes place in the group. Third, ourresearch did not focus on evaluating theeffectiveness of the responses but ratheron describing their nature. Thus, we shouldlimit the conclusions regarding the value ofthe group to stating that while it offerssuicidal individual a supportive environ-ment, we cannot draw conclusions aboutits effectiveness as compared to othersuicide prevention agencies such as tele-phone hotlines. We leave this to futureresearch.

AUTHOR NOTE

This manuscript is based in part on IzhakGilat’s doctoral dissertation, supervised byGolan Shahar (primary advisor) and YishaiTobin.

Itzhak Gilat, Levinsky College and theIsraeli Association for Emotional First Aid(ERAN), Netanya, Israel.

Yishai Tobin, Departments of Linguis-tics and Sociology=Anthropology, Ben-Gurion University of the Negev, Netanya,Israel.

Golan Shahar, Department ofPsychology at Ben-Gurion University ofthe Negev, Israel, and Department of Psy-chiatry, Yale University Medical School,

Correspondence concerning this articleshould be addressed to Itzhak Gilat, TheIsraeli Association for Emotional FirstAid, P.O.B. 7137, Netanya, Israel. E-mail:gilati@netvision.net.il

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