A Human Therapist's Take on Facebook's Suicide-Prevention Tool

Last week Facebook announced that it was taking steps to address the spate of suicides that have occurred on its site, especially on its streaming feature, Facebook Live. Apparently, social media platforms are seductive tools for individuals to communicate their suffering and suicidal intentions, or even to broadcast the ghastly acts themselves. Incidents in the last two months over Facebook Live have included a 14-year-old girlin Florida and a 12-year-old-girl in Georgia who hanged themselves and a 33-year-old man in California who shot himself.

The phenomenon is posing important questions for Facebook, as well as for users and their families. Is Facebook a community, like all communities, in which self-destructive and suicidal behavior takes place? Or is there something about this particular community—and perhaps about Facebook Live—that fosters it? What can Facebook do about it and how can it bring safety to the user experience?

In response to the problem, Facebook is expanding suicidal prevention initiatives that have been in place since2016. At the time, it introduced features that allowed users to flag posts that were concerning; that would lead Facebook to reach out to members in distress. Based on posts that were flagged, the company has now developed AI algorithms to identify concerning content. After review by a community operations team, Facebook will suggest that the at-risk user contact a friend, even offering a text introduction. And people can chat directly with various organizations, including the National Suicide Prevention Lifeline. A group of particular focus is users of FB Live.

The issue brought to my mind Ned, a 30-year-old advertising executive and compulsive Facebook user whom I have been seeing for several years in twice-weekly psychotherapy for depression. In the last two months, Ned has been suffering through an especially intense and intractable episode. I have become concerned for the first time that he could kill himself.

Ned is successful, Ivy-League-educated, and married to his college girlfriend, a corporate lawyer at a prestigious firm. They have just bought a home in a Boston suburb and are planning on starting a family. He is in love with his wife, doing well at work, and has good friends. He is kind, well-liked, and a solid, reliable member of the community. From an external point of view he is leading an enviable life and one for which he has long been preparing.

But Ned is tortured and depressed. He is not living the life he wants, but he does not know what he wants. He has always had the sense that he is destined for great things, however, the path he is on is not leading to greatness. He believes that his life should be bigger and full of potential. He feels trapped by his circumstances but has no vision of what could exist beyond being a husband, a father, and a corporate man. To me, Ned seems frozen.

He ruminates on what he perceives were past missteps—passions not developed, hobbies not pursued, books not read, courses not taken. And now it's too late. He longs to do it all over again. The present is intolerable because it is an outcome of the wrong past. The language we use in the sessions is that it is only a time machine that would allow him to feel better.

Facebook offers him a vision of alternate lives, options he could have pursed, all that he could have had. Ned spends hours scouring the profiles and posts of friends and enemies and colleagues until he debilitates himself with envy and hopelessness about his own life. It is not that people on Facebook only post information about their successes or that engaged dialogue doesn't take place on the site. But it is the case that someone like Ned can use social media to support his own naïve ideas about the seamless arc of a good life.

I think of Ned as someone who finds it very difficult to experience and tolerate sadness and loss. Ironically, it is the strength and single-mindedness of the wish to avoid sadness, to be released from it, its intolerability, that drives him into depression. "Doctor, you know I'm trying, right? All I want to do is feel better… Is there anything more I can do? Tell me, just tell me." What I try to help him learn is how to mourn: for all the paths he could have taken but chose not to, for the passage of time and the loss of a future with unlimited possibility, for people he could have been but now can never be. I teach him to accept his own history and his own choices, and to imagine the world of possibility and play within that history. These are muscles we must all learn to exercise.

In my experience—and this is supported by clinical research—two affects that put an individual at particular risk for suicide are psychic pain and shame. Ned is vulnerable to both. He comes to each session writhing, as if he is spilling blood from a knife sticking out of his chest. He hopes at each session that I will pull it out, suture his wound, and give him some morphine. But at the end of each meeting, the knife is always still there.

Psychoanalysts theorize shame as related to an individual's inability to see himself as he would like to be seen. That is, he harbors within himself a version of an ideal self, but he fails to live up to it. Ned enlivens himself with a grand vision of who he ought to be. He considers himself a tragic figure—failed, toppled, humiliated.

In the idealized universe of Facebook, Ned can find support for his distorted point of view, a point a view that calls into question the inevitability of limit, loss, and messiness. It is a point of view in which perfection is possible and, while time may pass, this passage only expands possibility, potential, and success rather than limiting them.

And indeed, there is grandiosity to killing oneself over Facebook Live. I am not suggesting that such individuals are not suffering. I suspect that they, like Ned, are in enormous psychic pain. But they are commanding attention for a big, bold, risky act, the performance to end all performances. Curiously, and especially among adolescents, suicidal acts can have a contagion effect and spread within a group. That is part of what makes a FB Live suicide so powerful and dangerous. Perhaps it is the envy over the refusal to compromise, the refusal to accept anything less than the ideal that accounts for the wish to copy such a final step.

We might hope for the Facebook community to function as what the British pediatrician and psychoanalyst Donald Winnicott called a "holding environment," a space of maternal-like care-taking and validation, where emotions, including angry and sad ones, can be expressed and absorbed. The holding environment is a place where risks can be taken and safety assured, where there can be a negotiation of internal experience and social reality. But I believe that for some users, Facebook suspends social reality and supports the childlike idea that anything is actually possible, that we can will the facts of our life to conform to our internal ideals of ourselves. Development teaches us to hold onto to the unlimited play of our imaginative selves; but that certain facts about us require a negotiation with external reality. In this version of the platform there is no distinction between the internal and the external. We are what we perform.

So, what should Facebook do?

Public health measures to prevent suicide are notoriously difficult to implement and to assess. One successful intervention took place on the Swedish island of Gotland in the early 1980s. General practitioners on the island were offered a two-day course in recognizing and treating depression. Ninety percent of the GPs on the small island attended. The course was given twice, once in 1983 and once in 1984, and in the years following this course the suicide rates on the island dropped precipitously.

Four years later, the suicide rate once again rose to baseline, indicating that the effects of the educational program had waned. And it suggested that it was the training program that had made the difference. Later analysis of the data showed that rates of suicide had come down largely through catching and treating depression within the female population. The men may have been reluctant to present to their doctors with complaints of sadness. Years later, the study is cited frequently as providing persuasive evidence of the importance of early detection of depression.

It is laudable that Facebook is taking steps to try to anticipate suicidal behavior. Predicting suicide is nearly impossible, however, even in the clinical setting. A study in The American Journal of Psychiatry estimated that 75 percent of suicide victims had contact with their doctor within a year of their deaths and 45 percent within one month, and yet those deaths were not prevented.

Screening for depression, however, is much more likely to be effective. With its access to the daily experience of its users, Facebook is in a unique and privileged position. It might broaden its mental health surveillance to screening for depression rather than focusing only on suicidal behavior and then connecting sufferers with resources. AI might be a particularly good tool for this.

Ned will survive, and even learn to experience joy, but that is because he is pursuing treatment for his depression—intensive psychotherapy and medication. Facebook could certainly be a useful portal into such treatment.

Hans R. Agrawal is a psychiatrist in private practice in Cambridge, Massachusetts.

Details have been altered to protect patient privacy.