Offline Versus Online Suicide-Related Help Seeking: Changing Domains, Changing Paradigms Amy-Lee Seward1 and Keith M. Harris2 1 2

Allambi Care, University of Newcastle The University of Queensland

Objective: Suicidal individuals are among the most reluctant help-seekers, which limits opportunities for treating and preventing unnecessary suffering and self-inflicted deaths. This study aimed to assist outreach, prevention, and treatment efforts by elucidating relationships between suicidality and both online and offline help seeking. Method: An anonymous online survey provided data on 713 participants, aged 18–71 years. Measures included an expanded General Help-Seeking Questionnaire General linear modeling results showed and the Suicidal Affect-Behavior-Cognition Scale. Results: that, as predicted, face-to-face help-seeking willingness decreased as risk level increased. However, for emerging adults help-seeking likelihood increased with informal online sources as risk increased, while other online help-seeking attitudes differed little by risk level. Linear regression modeling determined that, for suicidal individuals, willingness to seek help from online mental health professionals and online professional support sites was strongly related (ps < .001). Help seeking from social networking sites and anonymous online forums was also interrelated, but more complex, demonstrating the importance of age and social support factors (ps < .001). Conclusion: These findings show that the Internet has altered the suicide-related help-seeking paradigm. Online help seeking for suicidality was not more popular than face-to-face help seeking, even for emerging adults. However, treatment and prevention professionals have good reasons to increase their online efforts, because that is where some of the C 2016 Wiley highest risk individuals are going for help with their most severe personal problems.  Periodicals, Inc. J. Clin. Psychol. 72:606–620, 2016. Keywords: suicide prevention; help-seeking models; online behavior; Internet therapy; emerging adults

The World Health Organization (WHO; 2008) reports that close to a million people die every year by suicide. One of several factors that suicide victims likely have in common is communication of suicidal intent (Shneidman, 1996). Unfortunately, those communications may not include overt help seeking. Help-negation (not seeking help when it is needed) is all too common for those most in need (Offer, Howard, Schonert, & Ostrov, 1991; Stallman & Shochet, 2009). That may be particularly true for those suffering from suicidal crises (Deane, Wilson, & Ciarrochi, 2001; Harris, McLean, & Sheffield, 2014; Wilson, Deane, Marshall, & Dalley, 2010). The present study examined face-to-face and online help-seeking likelihood of suicide-risk individuals, with the aim of contributing to evidence-based outreach, prevention, and treatment strategies. Fortunately, opportunities for help are increasing, partly because of new technological developments. For example, there are a growing number of online treatment and communication options, such as online mental health professionals (e-MHPs) and 24-hour professional support services, which may appeal to some otherwise reluctant help-seekers (Christensen et al., 2014; van Spijker, van Straten, & Kerkhof, 2010). Part of the attraction of online support may come from less stigma, which results in greater self-disclosure (Burns, Davenport, Durkin, Luscombe, & Hickie, 2010; Joinson, 2004; Vogel, Wade, & Hackler, 2007). There is also evidence that individuals with mental disorders, including comorbid disorders and subthreshold symptoms, may spend more time online than others, making the online environment a bigger part of their daily lives (Aboujaoude, 2010; Harris et al., 2014; Starcevic & Aboujaoude, 2015). However, there is currently little information on who goes online for help, and where they go. Please address correspondence to: Keith M. Harris, School of Psychology, University of Queensland, St Lucia, Qld, Australia 4072. E-mail: [email protected]; [email protected] JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 72(6), 606–620 (2016) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp).

 C 2016 Wiley Periodicals, Inc. DOI: 10.1002/jclp.22282

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Help-Seeking Models Help-seeking models include the path model, which stipulates that intentions to seek counseling help are positively associated with distress and attitudes toward counseling (Cramer, 1999). An earlier study by Offer et al. (1991) showed mixed support for the path model, with “disturbed” adolescents (defined through measures of psychopathology, behaviors, and self-esteem) reporting greater likelihood than others for going to MHPs, substance abuse centers, and support centers, although they did not differ on seeking help from crisis hotlines or school counselors. The path model hypotheses, however, contrasts with some empirical findings showing higher risk has been associated with less help seeking (e.g., Harris et al., 2014; Wilson et al., 2010). An alternative to the path model is the prototype willingness model (PWM), which has demonstrated validity by explaining significant variance in psychological help seeking (Hammer & Vogel, 2013). The PWM includes help source availability, social, and situational influences as determinants of help-seeking behaviors. That is consistent with research examining a broad spectrum of help-seeking behaviors. Several studies have shown suicidality levels affect help seeking differently by source type (Deane et al., 2001; Harris et al., 2014; Wilson, Deane, Ciarrochi, & Rickwood, 2005; Yakunina, Rogers, Waehler, & Werth, 2010). For example, Wilson et al.’s (2010) study examined suicidality and help seeking from various sources. They found that suicide-related help seeking differed by two overall source types: informal sources, which they labeled family and friends (i.e., partners, friends, parents, and other family), and formal sources, which they labeled professional care (i.e., MHPs, telephone counseling services, and medical doctors). They also found, similar to Deane et al.’s (2001) study, that suicidality was negatively associated with seeking help from both formal or informal sources, which contrasts with the path model hypothesis. Those studies also helped validate the importance of availability, social, and situational factors for influencing help-seeking intentions.

Online Help Seeking There is considerable evidence that at-risk individuals are increasingly going online for physical and mental health purposes (Burns et al., 2010; Fox & Duggan, 2013; Mitchell & Ybarra, 2007). Harris, McLean, and Sheffield (2009a) earlier study also examined suicide-related help seeking through various help sources and introduced online help sources to the equation. That study found help seeking for suicide was negatively associated with depressive symptoms. A more recent study by Harris et al. (2014) reported help-seeking associations similar to Wilson et al.’s (2010). They found suicidality was negatively associated with help seeking for most help sources. However, suicidality was unrelated to the likelihood of going to anonymous online forums. That is a rare finding, showing suicidality was not negatively associated with suicide-related help seeking. That study also found evidence that suicidality was positively associated with going online to search for new friends, further demonstrating the importance of online communications for those high-risk and stigmatized individuals. Of importance to online therapists and prevention efforts, suicidal Internet users have also indicated that they found sites with open discussions to be the most useful, and they reported greater satisfaction with online communications that were anonymous or with people they felt were similar to themselves (Harris, McLean, & Sheffield, 2009b).

Construct Measurements Researchers have used a variety of measures to answer questions related to suicidality and help seeking. Some operationally defined help seeking as a dichotomous variable (yes or no) and/or assessed only a single help source (e.g., MHP). Several past studies also dichotomized suicide risk as present or absent (e.g., Harris et al., 2009b; Mitchell & Ybarra, 2007; Reynders, Kerkhof, Molenberghs, & Van Audenhove, 2014). However, dichotomizing predictor variables or outcomes reduces validity by limiting the amount of information available on the latent trait and should thus be avoided (Cox et al., 2012; Markon, Chmielewski, & Miller, 2011; Royston,

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Altman, & Sauerbrei, 2006). Others have used continuous measures of both help seeking and suicidality, as well as including a variety of help sources, providing greater depth and validity to their findings (e.g., Deane et al., 2001; Yakunina et al., 2010). Researchers have also differed by focusing on past help seeking with informal and formal (professional) sources (e.g., Offer et al., 1991) or future help-seeking probabilities, also referred to as help-seeking attitudes (Harris et al., 2014; Reynders et al., 2014; Wilson et al., 2010). There is, however, empirical evidence showing that past help-seeking behaviors and help-seeking intentions or willingness are strongly related. For example, Wilson et al. (2005) provided evidence that help-seeking willingness was predictive of actual help-seeking behaviors with several types of help sources, and Harris et al. (2009b) found evidence that suicidal individual’s reporting of past help-seeking behaviors was positively associated with future help-seeking intentions for various help sources. Therefore, although there can be important differences by help-seeking framework, examination of past behaviors and likelihood of future behaviors has led to complimentary information on how personal psychological factors, such as degree of suicidality, can affect help seeking. However, based on a significant body of empirical evidence (Markon et al., 2011), the assessment of both help seeking and related factors should be done through validated continuous measures.

Study Aims Although past studies consistently found suicidal individuals were less likely than nonsuicidal to seek face-to-face help for personal crises (Deane et al., 2001; Harris et al., 2014; Wilson et al., 2010; Yakunina et al., 2010), there is very little information on the degree of linearity between those factors, or their associations in an online environment. Based on that previous research we predicted that, overall, as suicidality increases, face-to-face help-seeking likelihood would decrease and help-negation would increase. We also predicted that online help seeking would, in contrast, show little or no associations with suicide risk level, similar to previous findings (Harris et al., 2014). We also explored which psychosocial and demographic variables best predict online help seeking by support type, i.e., e-MHPs (which include online psychologists, psychiatrists, counselors, etc.), professional support sites (e.g., Australia’s lifeline.org, and the suicidepreventionlifeline.org in the United States), social networking sites (e.g., Facebook, Twitter), and anonymous forums (where users might post asynchronous messages, engage in live chat, etc.).

Method Participants Of 713 anonymous online survey participants, 78.5% identified as Caucasian/White, 13.9% as Asian, and 7.6% as other ethnicities. They were aged 18–71 (mean [M] = 31.48, standard deviation [SD] = 13.53), and 77.1% were women. Education levels ranged from less than high school graduate (1.5%) to postgraduate degree holders (14.6%), with less than half (41.9%) holding at least a bachelor’s degree. Participants came from over 30 countries, about half (48.7%) from Australia. Most were from urban (42.2%) or other developed regions (36.3%), 17.5% were from rural areas, and 3.9% from very remote areas, as defined by the Australian Bureau of Statistics (2003). Participants reported 1–100 weekly hours online (M = 23.18, SD = 20.64). There were no student research participants, and no incentives were offered for participation.

Measures General Help-Seeking Questionnaire (GHSQ; Deane et al., 2001). The GHSQ assessed participants’ suicide-related help-seeking likelihood from several specified help sources, as well as the option to not seek help from anyone. We used the following question: “If you were experiencing suicidal thoughts, how likely would you seek help from any of the following?” Responses were made on a 7-point interval scale, with only anchor points labeled, ranging from 1 (extremely

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unlikely) to 7 (extremely likely). The GHSQ’s six help sources included partner (e.g., boyfriend, wife), parents, other relatives, friends, doctor (general practitioner), and mental health professional (e.g., psychologist/psychiatrist). For this study, we added the following additional help sources: online MHP (e.g., psychologist/psychiatrist), online support sites (run by a professional organization), social networks (e.g., Facebook, Twitter), and anonymous online forums. The GHSQ is an index, not a single-construct scale, and therefore scores are not summed. We did, however, find adequate levels of internal consistency. For the six face-to-face sources, α = .82, for the four online sources, α = .78. Suicidal Affect-Behavior-Cognition Scale (SABCS; Harris, Syu, Lello, et al., 2015). The SABCS assessed participants’ suicidality and was used to form groups by degree of suicide risk. The SABCS includes six self-report items that uniquely capture affective, behavioral, and cognitive aspects of suicidality and load strongly on one factor. The items are combined, with higher scores indicating greater current and future risk (range = 5–44). Multistudy analyses, based on associations with the latent trait and additional measures of personal distress, determined a method for grouping respondents as nonsuicidal (total = 5), low-suicidal (total = 6–13), moderate-suicidal (total = 14–28), and high-suicidal (total = 29–44; Harris, Syu, CouvyDuchesne, Ostini, & Renteria, 2016). The SABCS demonstrated superior reliability, construct validity, and predictive validity, over the highly endorsed Suicide Behaviors Questionnaire-Revised (Harris, Syu, Lello, et al., 2015). For this study, internal reliability was high, Cronbach’s α = .93, McDonald’s ωt = .95. Multidimensional Scale of Perceived Social Support (MSPSS; Zimet, Dahlem, Zimet, & Farley, 1988). The MSPSS was selected to assess participant’s perceived social support from three sources. Items were scored on a 7-point response set. Scores are totaled with higher scores indicating greater perceived support from that source. For this study, internal reliability was high, special person (which can include a spouse, or partner) α = .93; family α = .91; and friends α = .93. Online Relationship Initiation Scale (ORIS; Harris & Aboujaoude, 2016). The ORIS assessed participant’s use of the Internet to establish new interpersonal relationships (e.g., “Were you ever looking/hoping to make new friends online?”). Items were scored on a 5-point response set. Items are combined, with higher scores indicating greater online relationship development behaviors. For this study, internal reliability was high, Cronbach’s α = .90, McDonald’s ωt = .94. To help answer research questions on which psychosocial factors best predict online help seeking, we also included measures of personality (Zheng et al., 2008), satisfaction with life (Diener, Emmons, Larsen, & Griffin, 1985), depression, anxiety, and stress (Antony, Bieling, Cox, Enns, & Swinson, 1998); participant’s independent–interdependent problem solving (Rubin, Watt, & Ramelli, 2012); and weekly hours spent online. All scales showed adequate internal consistency (α ࣙ .80).

Procedure Ethics approval was obtained from the host institutional review board for participants older than 18 years of age. We chose an online survey because it is the most appropriate for our target population (i.e., suicidal Internet users), and because they have been found to be well suited for measuring psychological constructs in stigmatized groups and hard-to-reach populations (Joinson, 1999; Tourangeau & Yan, 2007). This was a purposive survey, hosted at a university web address, with oversampling of suicide-risk individuals to better examine variable associations. By promoting the survey as covering suicidality and other factors, past studies (e.g., Harris et al., 2009b) have been able to effectively obtain relatively large samples of the target population (i.e., suicidal participants). To ensure strict anonymity, no IP addresses or other identifying information were collected. Participants were recruited through Google and Facebook advertisements and snowballing. After confirming consent to participate and participants’ age (18+ years), they were asked to complete noncompulsory questions. When participants ended the survey, they were automatically taken to the exit page where they were given links and phone numbers to free and

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anonymous online support and were encouraged to use the support if they felt distressed. The survey took approximately 15–25 minutes to complete.

Data Analyses Data cleanup followed Tabachnick and Fidell (2006) with respect to normality, univariate and multivariate outliers, and missing values. Missing values analysis showed study variables met criteria for missing completely at random, and missing values were replaced through the expectation maximization method. For this study, 15.7% (n = 112) were grouped as nonsuicidal, 35.8% (n = 255) low-suicidal, 27.6% (n = 197) moderate-suicidal, and 20.9% (n = 149) high-suicidal. We first explored the data by plotting help-seeking trends by age group, sex, hours online, and suicide risk. Arnett (2000) demonstrated that emerging adulthood is a distinct and important developmental period. Empirical study has shown emerging adulthood to be a useful demographic for examining mental health factors (Sheets, Duncan, Bjornsson, Craighead, & Craighead, 2014; Sheets et al., 2013) and online behaviors (Nitzburg & Farber, 2013; Subrahmanyam, Reich, Waechter, & Espinoza, 2008). To preserve statistical power when analyzing age differences, and follow established protocol, we grouped participants by Arnett’s definition of emerging adults (aged 18–25 years; n = 400) and adults (aged 26+ years; n = 313) when appropriate. We next conducted general linear modeling (GLM) and Pearson correlations, by age group, to examine risk levels on help-seeking willingness by help source. We then used an iterative multiple regression modeling process to determine which variables best predicted help seeking from online sources. To increase the probability that these findings would represent population trends, we selected only predictor variables that were significant at p < .001. Data were analyzed using IBM SPSS (version 22), R v. 3.1.3 (R Development Core Team, 2015), and psych package (Revelle, 2014).

Results Demographic Factors Related to Help Seeking and Suicidality When we tested for possibly confounding factors by suicide risk status, chi-square tests revealed no statistically significant differences by sex or ethnicity (ps > .05). However, emerging adults (aged 18–25 years) were more likely to be in the higher risk groups than adults (aged 26–71 years), χ2 (3, N = 713) = 20.40, p < .001, Cramer’s V = .17. Interestingly, Pearson correlations, conducted separately by age group, showed hours online were not strongly related to any helpseeking attitudes, including with online sources (rs < .15). We next tested our prediction that suicide risk levels would be negatively associated with help-seeking willingness from face-to-face sources. Plots of help seeking by risk status showed similar trends by sex and age group. Figure 1, using the full sample, shows some support for our hypothesis that help-seeking willingness decreased, and help-negation increased, as suicidality increased. GLM analyses provided statistical evidence testing our hypothesis that face-to-face help seeking would be negatively associated with suicide risk level. Multivariate analysis of variance (MANOVA) results showed a significant group difference on the combined dependent variable of face-to-face help seeking, Wilks’ λ = .68, F(21, 2019) = 14.01, p < .0001. Follow-up analyses of variance (ANOVAs) showed significant main effects (p < .0001), for each help source. Planned comparisons were made between adjacent groups, i.e., nonsuicidal with low-suicidal, low-suicidal with moderate-suicidal, and moderate-suicidal with high-suicidal, all Bonferroni corrected. Table 1 shows that the moderate-suicidal group was significantly less likely to report help-seeking willingness from each source compared with the low-suicidal group, (ps < .001). Other group comparisons showed statistical differences in 7 of 14 comparisons, although all trends were in expected directions. Of importance, the high-suicidal group was most likely to choose no one for help, followed by friends, with partners and family their least likely sources of help.

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Figure 1. Help-seeking willingness (1 = extremely unlikely, 7 = extremely likely) by help source and suicide risk level.

Table 1 Comparisons Between Suicide Risk Levels on Face-to-Face Help-Seeking Probabilities Non (n = 112) Help source No one Friends MHP GP Partner Other relatives Parents

Low (n = 255)

Moderate (n = 197)

High (n = 149)

M

SD

M

SD

M

SD

M

SD

2.00 5.69 5.71 5.39 5.83 4.45 4.60

1.77 1.81 1.93 2.11 2.00 2.24 2.43

2.58† 5.32 5.18† 4.75∗ 4.90** 3.89† 3.93∗

2.01 1.85 2.03 2.10 2.37 2.24 2.34

3.72*** 4.35*** 3.95*** 3.60*** 3.89*** 2.49*** 2.75***

2.21 2.02 2.22 2.13 2.33 1.82 2.05

4.32† 3.58** 3.48† 2.94∗ 2.73*** 1.94† 1.85***

2.30 2.23 2.36 2.06 2.14 1.60 1.59

Note. Help sources ordered by mean scores of High-suicidal participants. M = mean; SD = standard deviation; MHP = mental health professional; GP = general practitioner (medical doctor); non = nonsuicidal; low = low-suicidal; moderate = moderate-suicidal; high = high-suicidal. Analysis of variance comparisons are with the group immediately to the left of the reference group. Help-seeking: 1 = extremely unlikely, 7 = extremely likely. ∗ p < .05. ** p < .01. *** p < .001. Bonferroni corrected; † p < .05 (uncorrected).

We next examined online help-seeking likelihood by risk level. Because initial plots showed age group differences, but no differences by sex, online help seeking was examined separately by age group. In contrast to expectations, Figure 2 shows there were some variations in online help seeking by suicide-risk level. Seeking help from professional sources (i.e., e-MHPs and support sites) showed similar trends as with face-to-face sources. That is, help-seeking likelihood generally decreased as suicidality increased. Unexpectedly, for emerging adults, help-seeking willingness through informal online sources, social networking sites, and anonymous forums showed signs of increasing as suicidality increased. For adults, informal online help seeking was relatively constant across the suicidal levels. We next conducted GLM to further test the above help-seeking trends. For emerging adults, MANOVA results showed a statistically significant difference on online help-seeking willingness, Wilks’ λ = .91, F(12, 1040) = 3.17, p < .001. Follow-up ANOVAs showed a significant main effect only for social networking (p < .001). For adults, MANOVA results showed no statistically significant group difference on online help seeking, Wilks’ λ = .94, F(12, 810) = 1.58, p = .09.

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Figure 2. Online help-seeking willingness (1 = extremely unlikely, 7 = extremely likely), by help source and suicide-risk level, of emerging adults (A) and adults (B).

Table 2 Comparisons Between Suicide Risk Levels on Online Help-Seeking Probabilities, by Age Group Non Age/help source Emerging adults Support sites E-MHPs Social net Forums Adults Support sites E-MHPs Forums Social net

M

Low SD

(n = 51) 4.12 2.11 4.02 2.26 2.08 1.74 2.61 1.99 (n = 61) 3.95 2.19 3.95 2.31 2.30 1.93 2.07 1.70

M

Moderate SD

(n = 127) 3.86 2.10 3.77 2.14 2.52 1.87 2.88 1.96 (n = 128) 3.59 2.11 3.46 2.14 2.55 2.00 2.38 1.92

M

SD

(n = 133) 3.38 2.13 3.22† 2.14 3.19† 2.11 2.83 2.08 (n = 64) 3.09 2.03 3.03 2.08 2.70 1.91 2.16 1.59

High M

SD

(n = 89) 3.64 2.33 3.44 2.32 3.38 2.34 3.28 2.30 (n = 60) 3.03 2.26 2.97 2.26 2.33 1.98 1.97 1.86

Note. Help sources ordered by mean scores of high-suicidal participants. M = mean; SD = standard deviation; MHP = mental health practitioners; non = nonsuicidal; low = low-suicidal; moderate = moderatesuicidal; high = high-suicidal; E-MHP = online MHP; forums = anonymous online sites. Emerging adults = aged 18–25 years; adults = aged 26–71 years. Help-seeking: 1 = extremely unlikely, 7 = extremely likely. † p < .05 (uncorrected).

Table 2 shows, after Bonferroni corrections, that there were no statistically significant differences between adjacent risk groups. We therefore examined these trends through bivariate correlations to determine if the observed trends were supported by statistically significant associations. Pearson correlations showed that e-MHP help-seeking willingness was negatively, but weakly, associated with suicidality for adults (r = -.15, p = .007). For emerging adults, willingness to go to social networking sites for help showed a small positive association with suicide risk (r = .21, p < .001). There were no other statistically significant trends.

Demographic Variables and Help Seeking Beyond age, we examined other demographic variables in relation to help-seeking intentions. Pearson and point-biserial correlations, conducted separately by age group, showed only one small association at r ࣙ .20. For adults, education level was positively associated with willingness to seek help from offline MHPs, r = .21, p < .001. There were no meaningful associations between

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Table 3 Linear Regression Models Predicting Online Mental Health Professional and Support Site HelpSeeking by Suicidal Participants (n = 600) 95% CI Help source/predictor E-MHP Support site help MHP help Constant Online support site E-MHP help Forum help Constant

B

SEB

β

LL

UL

.74 .16 .07

.03 .02 .12

.74*** .17***

.69 .12 −.17

.79 .21 .30

.73 .17 .58

.03 .03 .10

.73*** .16***

.67 .11 .38

.78 .22 .78

Note. CI = confidence interval; MHP = mental health professional; MHP help = likelihood of going to mental health professionals for help; e-MHP help = likelihood of going to online MHPs for help; forum help = likelihood of going to anonymous online forums for help. E-MHP: R2 = .67. F(2, 598) = 619.27, p < .0001. Support site: R2 = .67. F(2, 598) = 607.27, p < .0001. *** p < .001.

sex, ethnicity (dichotomized as Caucasian/White vs. other), urban versus rural residence, or education and other help-seeking sources. As we observed important age group differences for online help seeking, but not for other demographic variables, we compared the two age groups by suicidality and help seeking. One-way ANOVAs showed no age group differences in online help-seeking willingness for nonsuicidal and low-suicidal participants. For moderate-suicidal participants, emerging adults were more likely than adults to choose social networking, and for high-suicidal participants, emerging adults were more likely to choose both social networking and forums for support (ps < .05).

Predictors of Online Help Seeking by Source Type We then tested our research questions on which factors best predict online help seeking for each source type. We excluded the nonsuicidal group because we were interested in the help-seeking willingness of those in need, resulting in a subsample of 600. For the following analyses, we made an a priori decision to include only predictors that were significant at p < .001. For each online help source, we first examined the bivariate associations between potential predictor variables (e.g., perceived social support, depressive symptoms, problem-solving style, personality type, specific suicidal attributes, and sex) with help-seeking likelihood. That process showed that many of the study variables lacked linear associations with help seeking, and therefore those predictor variables were excluded. Our first two regression models predicted use of professional online support (e-MHPs and support sites) and were remarkably similar. Both models predicted a significant 67% of the variance in help-seeking likelihood for each source. Table 3 shows willingness to go to e-MHPs and that support sites were strongly interrelated. Willingness to seek face-to-face MHP help also made a significant, but smaller, contribution to explaining e-MHP help seeking, indicating that the suicidal people going to e-MHPs are oriented toward professional support, both offline and on. We named them professional help-seekers. Online forum use likelihood also made a significant, but smaller, contribution to explaining support site help seeking. We named those individuals anonymous online Help-seekers. Of note, no other psychosocial or demographic variables, or weekly hours online, helped explain these online help-seeking probabilities. Our next regression models predicted help-seeking willingness through online social networks. Table 4 shows that suicidal participants who were likely to choose social networking sites were also likely to choose anonymous online forums, for both age groups. Final model variables

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Table 4 Linear Regression Models Predicting Social Network Help-seeking by Age Group for Suicidal Participants (n = 600) 95% CI Age group/predictor Emerging adults (18–25 years) Friends help Forum help ORIS Family support Constant Adults (26–71 years) Forum help E-MHP help ORIS Relatives help Constant

B

SEB

β

LL

UL

.37 .34 .06 −.05 −.22

.05 .04 .01 .01 .35

.36*** .34*** .25*** −.20***

.28 .25 .04 −.08 −.91

.47 .43 .08 −.03 .47

.28 .18 .05 .15 −.28

.06 .05 .01 .04 .28

.30*** .22*** .20*** .18***

.17 .08 .02 .07 −.82

.39 .28 .07 .23 .27

Note. CI = confidence interval; MHP = mental health practitioner; ORIS = Online Relationship Initiation Scale. Friends help = likelihood of going to friends for help; forum help = likelihood of going to anonymous online forums for help; family support = perceived social support from family; e-MHP help = likelihood of going to online mental health professionals for help; relatives help = likelihood of going to nonimmediate family for help. Social networking emerging adults: R2 = .36. F(4, 342) = 48.59, p < .0001; adults: R2 = .34. F(4, 247) = 31.13, p < .0001. *** p < .001.

predicted 36% of the variance in the likelihood of suicidal emerging adults going to social networking sites for help, and 34% of the variance for suicidal adults. For emerging adults, perceived social support from friends, a history of going online for new personal relationships (ORIS scores), and lack of perceived family support all contributed to the model predicting social network help seeking. We named this group online + friend helpseekers because of the importance of the perceived social support from friends and their interest in going online to develop new social relationships and to online forums for help. For adult participants, a history of going online for new personal relationships and perceived support from relatives (excluding partners and parents) helped predict social network help seeking. We named them online extended help-seekers because they reported a willingness to go to online forums, e-MHPs, and extended family for help and were also involved in going online for new social relationships. Our last regression model predicted help-seeking likelihood through anonymous forums. Willingness to seek help from support sites and social networking sites explained 35% of the variance in emerging adults’ help-seeking likelihood at forums. We named this group online informal help-seekers because they indicated willingness to go to all online help sources other than e-MHPs. Table 5 shows that those two factors were also most important for adult help seeking from forums. In addition, a perceived lack of support from a special person (e.g., romantic partner), and perceived support from family, made significant contributions to the model, explaining 42% of the variance in forum help-seeking likelihood. We named this group online solitary informal help-seekers because they differ from emerging adults by the importance of a lack of perceived support from a special person.

Discussion This study examined help-seeking willingness for both offline and online sources by degree of suicide risk. As expected, we found the likelihood of seeking help from both personal (informal) and professional (formal) face-to-face sources decreased as suicidality increased, while help

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Table 5 Linear Regression Models Predicting Anonymous Online Forum Help-seeking by Age Group for Suicidal Participants (n = 600) 95% CI Age group/predictor Emerging adults (18–25 years) Online support site help Social networking site help Constant Adults (26–71 years) Online support site help Social networking site help Special person support Family support Constant

B

SEB

β

LL

UL

.40 .32 .55

.04 .04 .20

.41*** .32***

.31 .23 .16

.49 .40 .94

0.36 0.38 −0.08 0.05 1.00

.05 .06 .01 .02 .26

.39*** .35*** −.34*** .23***

0.26 0.27 −0.11 0.03 0.49

0.45 0.49 −0.05 0.08 1.52

Note. CI = confidence interval. Emerging adults: R2 = .35. F(2, 345) = 91.17, p < .0001; adults: R2 = .42. F(4, 246) = 45.05, p < .0001. Online support site help = likelihood of going to online support sites for help; social networking site help = likelihood of going to social networking sites for help; special person support = perceived social support from a special person (spouse, partner, etc.); family support = perceived social support from immediate family. *** p < .001.

negation increased. In contrast, willingness to seek help from online sources showed mostly small and less consistent differences by suicidality. Of note, for emerging adults, informal online sources, particularly social networking sites, were positively associated with suicide risk. That is an unusual finding. These results substantiate the linear relationship between suicidality and help-seeking willingness for face-to-face but not online sources. There were also indications in our results that online support appears more acceptable for younger adults. The Internet, therefore, may be providing a unique domain for help seeking, thus changing the paradigm for those most in need.

Online Help Seeking by Help Source We also examined factors that might predict suicide-risk individuals’ likelihood of seeking help from specific online source types. Similar to previous studies, we found that online help seeking was somewhat similar to offline help seeking, as evidenced by a split between formal and informal sources (Harris et al., 2014; Wilson et al., 2005; Yakunina et al., 2010). The similarities ended there, however. Likelihood of going to online mental health professionals was best predicted by willingness to go to professional online support sites, and vice versa. We tentatively refer to those individuals as professional, and anonymous, online helpseekers because those willing to go to e-MHPs were also willing to go to face-to-face MHPs, while some were oriented toward only anonymous online sources. Similarly, willingness to go to social networking sites and anonymous forums was also interrelated. We tentatively refer to those individuals as online + friend help-seekers and online extended help-seekers because their online help seeking was also associated with perceived friend and family support. There were also some differences between emerging adults and adults in predicting informal online help-seeking likelihood. However, a history of going online for new personal relationships (ORIS scores) and perceived social support were important factors for both age groups, highlighting the importance of the Internet as a social environment.

Implications for Help Seeking Models Consistent with the prototype willingness model, availability of resources and social factors appear to be highly relevant to suicidal online help seeking. The Internet is available, to a growing

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segment of the world population, on a 24/7 basis. That would help explain why many suicidal individuals would go online for immediate help. The social factors affecting help seeking are clearly seen in differences between help seeking with formal, informal, and anonymous sources. Our findings supported previous research showing suicide risk was related to greater likelihood of online interpersonal communications (Harris et al., 2009b; Mitchell & Ybarra, 2007), and that social support is related to help seeking but can differ by help source (Yakunina et al., 2010). Results also provided partial support for the pathway model. Suicidality was positively associated with help-seeking intentions through social networking, although only for emerging adults. Consistent with previous findings (Deane et al., 2001; Harris et al., 2014), this study found that individuals have preferences, or dispositions, for seeking help from sources related to their degree of anonymity or professional standing. These typologies do not necessarily fit well with any particular help-seeking model, but are likely to be of interest to MHPs and others offering support and treatment. Here, we tentatively labeled help-seeking types as online professional help-seekers, online anonymous help-seekers, online + friend help-seekers, etc. While those help-seeking typologies require confirmation through follow-up research, findings clearly showed online source types (e.g., social networking, professional support sites) attract suicidal individuals with varying help-seeking dispositions. Importantly, and surprisingly, help-seeking types were unrelated to any assessed psychosocial or demographic factors (e.g., sex, depression, degree of suicidality, and weekly hours online), other than age, online relationship development (ORIS scores), and perceived social support. These findings fit well with previous research that found that suicidal Internet users reported greater satisfaction with online support that was anonymous and with similar people (Harris et al., 2009b). Typologies such as online professional help-seekers showed similarities with those who seek offline professional support (Deane et al., 2001; Offer et al., 1991). However, those who go to social networking and online forums and who tended to be younger and higher risk are of great concern. How many of those individuals will get sufficient help to reduce or end their suicidality? How many will get no suitable help and succumb to suicidal feelings? Those are, clearly, the at-risk individuals that mental health professionals should be most concerned about but are least likely to see because of the individual’s help-seeking inclinations. This study showed that current help-seeking models do not sufficiently explain online helpseeking trends. Online physical and mental health services are growing (Fox & Duggan, 2013), however, and the variables associated with who goes online for support, where they go, and why they choose online support all deserve more attention. Online self-help treatment for suicidality has been developed (van Spijker et al., 2010) and has been shown to be effective (van Spijker, Cristina Majo, Smit, Van Straten, & Kerkhof, 2012). Of interest, a randomized controlled trial found that online treatment of suicidality, through a professional support site, was as effective as face-to-face treatment (Christensen et al., 2013). What appears to be lacking is research on the effectiveness of linking support source types, such as e-MHPs with both professional support sites and informal sites (e.g., social networking and forums).

Limitations and Future Directions There were some important limitations to the present study. Although several standardized measures of psychosocial constructs were included, and several demographic characteristics assessed, there were also some important variables that were not included in the survey. For example, Wilson, Rickwood, Bushnell, Caputi, and Thomas (2011) found that need for autonomy was a contributing factor for informal help seeking. It may be that individual differences in need for autonomy, or attitudes toward help sources (Cramer, 1999), also help predict online help seeking by source type. The online sample of the present study was very useful for examining associations between the assessed constructs. However, this sample does not map to a specific geopolitical region. Further testing is also required to confirm whether variable associations hold true for adolescents, non-English speakers, and other ethnicities. For example, recent research found MHP help-seeking differences between Asian and White American university students

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(Wong, Brownson, Rutkowski, Nguyen, & Becker, 2014). Further study is required to test those relationships with nonstudents and for additional help sources, including online support.

Implications The findings of the present study have important implications for outreach efforts. Regression modeling demonstrated strong associations between those who go to social networking and anonymous forums for help. Because those sources were also somewhat popular for highest risk emerging adults, it is clear that many younger high-risk individuals can be found looking for help in those environments. If professional support organizations want to reach them, then they need to have a presence, and perhaps a cooperative arrangement, with such services. Doing so could result in more online + friend help-seekers and online Informal help-seekers getting professional support and treatment. Similarly, because e-MHPs and professional support sites are attracting much the same clientele, cooperation, or integration, of the two types of professional help could help better meet the needs of those individuals. Overall, these results show that suicide-risk individuals who are willing to go online for help tend to have preferences for a type of support. As younger adults, particularly those at highest risk, prefer social networking and anonymous forums, those are the areas professionals should be learning more about and finding ways to reach out to those in need to get them the support and treatment they require.

Conclusion These findings recall the age-old question: Should mental health professionals focus on treating those most at-risk or most of those at-risk? Our findings show that the highest risk participants were likely to avoid seeking help, but, especially for emerging adults, those high-risk participants reported attraction to online support. While empirical evidence appears to show that most individuals would prefer face-to-face mental health support, that may not include those most at-risk (Berle et al., 2015). Although there have been recent trends toward integration of online support services, much more needs to be done. Professional support providers might reach more high-risk individuals through better integration of support and social networking sites, as well as including more anonymous forms of therapy such as a program developed in the Netherlands (van Spijker et al., 2012). Better integration of e-MHP and other online support could allow for broader types of assistance. For example, support sites might refer some individuals to accredited e-MHPs and MHPs (depending on the help-seekers preferences). E-MHPs might direct some individuals to 24/7 chat lines and support forums for after-hours support. Further efforts in social network support such as professional and informal sources that are connected to nonmental health networks could improve awareness and outreach for currently isolated communities, such as online gamers. This study provided additional evidence that individuals in need will find and use alternative mediums, thus altering previous client-treatment paradigms. It is then up to pioneering therapists and support organizations to adapt and respond to those most at-risk.

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