Suicide and Life-Threatening Behavior © 2016 The American Association of Suicidology DOI: 10.1111/sltb.12286
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Evaluation of the 113Online Suicide Prevention Crisis Chat Service: Outcomes, Helper Behaviors and Comparison to Telephone Hotlines JAN K. MOKKENSTORM, MD, MERIJN EIKELENBOOM, LLM, ANNEMIEK HUISMAN, PHD, JASPER WIEBENGA, MSC, RENSKE GILISSEN, PHD, AD J. F. M. KERKHOF, PHD, AND JOHANNES H. SMIT, PHD
Recognizing the importance of digital communication, major suicide prevention helplines have started offering crisis intervention by chat. To date there is little evidence supporting the effectiveness of crisis chat services. To evaluate the reach and outcomes of the 113Online volunteer-operated crisis chat service, 526 crisis chat logs were studied, replicating the use of measures that were developed to study telephone crisis calls. Reaching a relatively young population of predominantly females with severe suicidality and (mental) health problems, chat outcomes for this group were found to be comparable to those found for crisis calls to U.S. Lifeline Centers in 2003–2004, with similar but not identical associations with specific helpers’ styles and attitudes. Our findings support a positive effect of the 113Online chat service, to be enhanced by practice standards addressing an apparent lack of focus on the central issue of suicidality during chats, as well as by the development of best practices specific for online crisis intervention.
Crisis telephone helplines, or “hotlines,” are a valuable resource in community suicide prevention (WHO, 2014), and a growing
body of evidence has consistently shown that helplines reduce distress and suicidality in many callers (Coveney, Pollock,
JAN K. MOKKENSTORM, Department of Psychiatry, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, 113Online Foundation, Amsterdam and Department of Research & Innovation, GGZIngeest, Amsterdam, The Netherlands; MERIJN EIKELENBOOM, Department of Psychiatry, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, and Department of Research & Innovation, GGZIngeest, Amsterdam, The Netherlands; ANNEMIEK HUISMAN, 113Online Foundation, Amsterdam, and Department of Clinical Psychology, The EMGO Institute for Health and Care Research, Faculty of Psychology and Education, VU University Amsterdam, Amsterdam, The Netherlands; JASPER WIEBENGA and RENSKE GILISSEN,
113Online Foundation, Amsterdam, The Netherlands; AD J. F. M. KERKHOF, 113Online Foundation, Amsterdam, and Department of Clinical Psychology, The EMGO Institute for Health and Care Research, Faculty of Psychology and Education, VU University Amsterdam, Amsterdam, The Netherlands; JOHANNES H. SMIT, Department of Psychiatry, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam and Department of Research & Innovation, GGZIngeest, Amsterdam, The Netherlands. Address correspondence to J. K. Mokkenstorm, Department of Psychiatry and EMGO Institute for Health and Care Research, VU University Medical Center, A.J. Ernststraat 1187, 1081 HL Amsterdam, The Netherlands; E-mail:
[email protected]
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EVALUATION
Armstrong, & Moore, 2012; Gould, Cross, Pisani, Munfaks, & Kleinman, 2013; Gould, Jimmie, Munfakh, Kleinman, & Lake, 2012; Gould & Kalafat, 2009; Gould, Kalafat, Harris-Munfakh, & Kleinman, 2007; Lester, 2012; Mishara et al., 2007b). Recognizing the importance of digital communication, major crisis helpline organizations began to offer online help services via chat (instant messaging) and e-mail (Drexler, 2013; Mishara & C^ ote, 2013; Murphy, 2013). As the rollout of these emerging online services preceded research, the need for evaluation of processes and outcomes is of great importance (Christensen, Batterham, & O’Dea, 2014; Luxton, June, & Kinn, 2011; Mishara & C^ ote, 2013). Since its opening in 2009, the Dutch suicide prevention organization 113Online provides several online services to persons in suicidal crisis, ranging from volunteeroperated helplines to an online self-help course (van Spijker, van Straten, & Kerkhof, 2014), self-assessment tests, and brief online psychotherapy (Mokkenstorm, Huisman, Kerkhof, & Smit, 2013). These services can be used by 113Online visitors anonymously and free of charge. To evaluate the 113Online crisis chat service, we applied the methods and measures used in the Silent Monitoring Study of Telephone helplines (SMST; Mishara et al., 2007a,b). This approach was chosen because it does not interfere with active 113Online helpline functioning and ensures a naturalistic observation of helpers’ and chat visitors’ behaviors. In addition, replication of the use of SMST instruments allows for a direct comparison of the crisis chat service with outcomes of crisis telephone helpline services observed in 2003 and 2004. In this period, Mishara et al. (2007a, b) monitored 1,431 crisis calls, including 503 suicidal crisis calls, to 14 centers of the U.S. National Lifeline Centers (which at that time were referred to as U.S. 1-800SUICIDE Lifeline Network Centers). Through silent listening, Mishara et al. rated visitors’ emotional states and suicidal ambivalence in the first and last 2 minutes
OF THE
113ONLINE CRISIS CHAT SERVICE
of calls using the Crisis Call Outcome Rating Scale outcomes (CCORS; Bonneson & Hartsough, 1987) at the end of calls; and scored helpers’ behaviors and attitudes throughout the call. Overall, Mishara et al. (2007b) observed a modest positive effect of telephone crisis calls, with many variables not changing significantly from the beginning to the end of the call. When change did occur, it was much more likely to be in the direction of improvement, with deterioration sometimes occurring. Mishara et al. (2007a) described four helper styles based on factor analysis of helper behaviors observed during hotline calls: (1) supportive approach and good contact, (2) collaborative problem solving, (3) active listening, and (4) negative approach. The first two styles, together with empathy and respect, were significantly related to positive outcomes. Active listening was not significantly related to positive outcomes. A mixed score of helpers’ directivity yielded better outcomes than high levels (completely leading the course of the call) and low levels (totally following the lead of the caller) of directivity, respectively. The goals of this study were to assess the reach of the 113Online chat service; to determine to what extent the 113Online crisis chat outcomes and their relation to helper styles are comparable to those found for telephone crisis calls; to identify areas for improvement of this service; and to formulate directions for future research.
METHODS
Sample 113Online chat logs were recorded automatically in real time and without further processing on a secure dedicated server in the 113Online medical records database. From this database, 526 chat logs of interactions with 78 volunteer helpers were retrieved from a total of 1,732 consecutive chat logs recorded between April 1 and June 1, 2013. The inclusion criteria were first chat visits per IP address with a
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duration of 20 minutes or longer pertaining to visitors who were in crisis. Not included were chats too short in duration to make a proper assessment (n = 512), repeat chats with visitors whose first chat in the study period was already included (n = 666), chats with people seeking help for someone other than themselves and/or those bereaved by suicide (n = 24), and noncrisis chats referred to 113Online professionals (n = 4) (see Figure 1). Among visitors whose chats had been included, the mean number of chats during the 2-month study period was 2.2 (SD = 3.7, range 1–31). Procedure and Analyses Each of the included chat logs was coded by two independent coding research assistants: one coded outcomes and one coded helpers’ behaviors and attitudes. Research assistants were working on a voluntary basis, with no previous experience as a 113Online helper. They were trained in the application of the SMST coding manual and coding forms using representative chat
All answered chats 113Online April and May, 2013 (n=1,732)
Chat duration 20 min. or longer (n=1,220)
Chat duration
