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13 Reasons Why – A Clinical Perspective on Suicide Contagion

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13 Reasons Why – A Clinical Perspective on the Graphic Depiction of Suicide

By Elizabeth Weinberg, MD, and Katie Lewis, PhD

This is part three of a three-part series offering a clinical perspective on the Netflix series, 13 Reasons Why (originally published on May 4, 2017).

Part 3: Suicide Contagion

Reportedly, the writer and producers who created 13 Reasons Why believed that the very explicit suicide scene would help discourage people from attempts (Nic Sheff, Vanity Fair, April 19, 2017), despite clear and convincing evidence that graphic depictions of suicide often have the opposite effect, especially among young adults. Interestingly, the show illustrates clearly the phenomenon of suicide contagion: for example, Hannah’s suicide directly contributes to an attempt by one of her friends, and several of her other friends either seriously consider suicide, or become otherwise more self-destructive. While the show demonstrates the danger of contagion, the creators appear not to have considered how their particular approach to presenting the series may create similar vulnerabilities and danger in young viewers. Suicide is fundamentally an irrational act that occurs in a state of tremendous distress. When a suicide occurs, this increases feelings of pain and guilt, as well as making suicide feel more accessible. For this reason, showing Hannah’s suicide in such detail seems likely to be counterproductive.

There are signs that the creative team responsible for 13 Reasons Why plans to make a sequel. This is disturbing, as this again suggests that the material in this show is being used primarily for entertainment. If these plans proceed, it is to be hoped that the writer and director will proceed more thoughtfully and in consultation with experts in the field of suicide research and prevention.

The Jed Foundation, a nonprofit group organized to help prevent youth suicide, has issued specific guidelines, which can be viewed on their website.

Here are a few DOs and DON’Ts related to 13 Reasons Why:

  • DON’T watch this show if you are feeling like you might be vulnerable or if the idea of it makes you uncomfortable.
  • DO, if you are a parent, find out if your children have watched this show. If they plan to watch it, consider watching it with them.
  • DO watch the show critically, thinking through Hannah’s decision and her friends’ decisions, noticing where there actually were caring relationships and missed opportunities.
  • DO use the show as an opportunity to talk about other issues that appear, like dealing with coming out, gun violence, and drunk driving.
  • DO use this as an opportunity to ask about suicidal thoughts and feelings. If you are having suicidal thoughts or feelings, ask for help, using the resources from the Jed Foundation, or a therapist or counselor.

Educators and parents may additionally find the considerations and cautions provided by the National Association of School Psychologists to be a useful resource.

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Comments

Hi! I have read your blog posts and appreciate the care and concern that they reflect. I feel it's best to ask questions in matters of disagreement- especially when assumptions (among other things) may distort or perceptions of the positions held by people that want "similar things" for humanity. So: Does the research indicate that suicide attempts escalate above and beyond that which is average following a (graphic) depiction of suicide in a drama as opposed to it being a celebrity or person known to an individual? What happens to those numbers in the following months? Could there be a lot more benefit to viewing the film/series than you are acknowledging? Isn't trauma and untreated psychopathology the major preceding factors in suicidal behavior? What do you think the show intends to treat? What did you think of the Hurt Locker and Before I Fall?  I also appreciated the guidelines you offered as to when this is best watched. Lots more questions to follow! Thanks, Kevin

Dear Kevin,

We appreciate your thoughtful response to our blog posts. You clearly read what we wrote carefully and perceptively. It's difficult to engage in a full conversation by means of blog postings and responses, but we want to respond to the points you made. We absolutely agree that people do not necessarily want the same things as one another, and that how the series, 13 Reasons Why, lands with viewers will depend on highly individual factors. Perhaps one of the greatest reasons for our concern has been the way this series has become explosively popular with young teens and tweens, with reports that it has been watched by viewers as young as 8. Unlike shows that were created to be shown on TV or in movie theaters, 13 Reasons Why wasn't screened to assure that it was appropriate for its audience. While it was released with an MA-17 rating, there isn't any meaningful way to ensure this rating is observed, and in fact the high school setting and adolescent themes make it likely this show would be most popular with younger teenagers. From this point of view, we wanted to note this series includes extremely graphic and disturbing content that simply is not appropriate for pre-adolescent children and younger teens.

It has been known for a long time that depictions of suicide can influence suicidal behavior.  This has been called the “Werther effect,” after the surge of suicides that followed the publication of Goethe’s The Sorrows of Young Werther. Empirical research has shown that suicide rates increase following exposure to fictional depictions of suicide, especially in teens, who can be particularly influenced by suicides from the same age group.  (See link for a full review of the evidence). It is true that we don’t have much evidence to support specific guidelines for portrayal of fictional characters.  We are assuming that the same practices that have been useful in media portrayals of real suicides are applicable. 

Raising public awareness of suicide is important, but others have achieved this without the kind of dramatic, explicit portrayal that appears particularly risky.  We agree that suicide can have many causes that certainly can include mental illness and trauma.  Nevertheless, an individual moving towards a suicide attempt can be influenced positively or negatively by external influences, and contagion through media depictions of suicidal behavior has been shown to impact individuals at risk. While raising the issue of youth suicide remains an important task, efforts to achieve this goal must be undertaken with consideration of the best currently available guidelines and research.

Having said that, we absolutely agree that there could benefit for some viewers in watching 13 Reasons Why. It is a well-written series that highlights important, real concerns. We particularly appreciated how three-dimensional the characters in the series appeared to be, and that each event is depicted from a variety of points of view. The series depicted dilemmas relating to adolescent sexuality, the coming-out process, social exclusion, substance use, and bullying in a nuanced manner that is praiseworthy. Decisions about graphic portrayal of disturbing content are usually up to writers and artists to weigh, and there are many very troubling books and movies that make powerful and important statements. In this case, the concerns specifically relate to the impact of this series on what appears to be its target audience, young teenagers, as well as younger children, and emotionally unstable or suicidal individuals of any age who may be "binge-watching" it on their own without support – a very different experience from seeing a movie with others in a theater. Our comments are intended to help and support viewers as well as parents and educators in thinking about whether to (and how to) watch the series, and the importance of speaking about it with younger viewers, who may be left with difficult questions and feelings they are too young to handle on their own.

Drs. Weinberg and Lewis

Hi Drs. Weinberg and Lewis, 

           Thank you for response. The link you provided included most of the literature that I am familiar with on this subject matter (e.g., Dr. Stack). I have observed that adults (particularly those that treat mental health) are binge-watching this series as well, which has led to an increase in discussions on these topics, changes in the types of questions being asked of school administrators, further developed suicidality/bullying/isolation (etc.) as larger parts of the assessment process, and influenced a more watchful awareness of school culture. I would, however, hope to see more examples of young people that struggle with suicidality but are met with effective treatment that leads to improvement (e.g., Ordinary People). Also, I agree that there is so much media that makes it's way into the hands of younger audiences that is inappropriate and overwhelming- at the same time, art is the major vehicle that society has to not only capture and express it's concerns, but to ask for the attention and healing it needs. I am hopeful that this show leaves such an imprint on parents/caretakers, policy-makers, school administrators, mental health professionals that will lead them to prioritize and address bullying, rejection, substance-use, sexuality, self-esteem/self-image, isolation, ingroup/outgroup status and psychopathology, as we are in an era where mass-shootings and suicide is becoming the norm.

-Kevin

Dear Kevin,

We appreciate your observations and agree that addressing issues of bullying, isolation, and other troubling interpersonal experiences (in addition to psychopathology) is an important goal and responsibility. In line with this, in one of our current research studies here at Austen Riggs, we do ask participants about their experiences of bullying and trauma, as well as details about their daily interpersonal experiences and how these experiences relate to depression and resilience. Through this work, we hope to be able to contribute to existing knowledge of how interpersonal experiences influence suicide and self-harm risk over time and to eventually provide guidance to mental health practitioners about addressing these concerns in treatment. Thank you again for your thoughtfulness in raising these important questions!

Unfortunately these are the things that should be addressed properly and bullying is without any doubt one of the biggest problems for mental health. Mental health is really important and it is as important as physical health but unfotunately we don't discuss it more and don't give it the importance it deserve. I am trying to conduct a session for my colleagues of Penny Saviour because we need to conduct these sessions more often.

Before I dive into my thoughts on this television show as a whole, I'd like to state that I'm going to be leaving the controversy out of it. There are many people who think this show is just going to help people do the wrong thing, but I believe this is an eye opener to everyone else on how little things people do on a daily basis can affect someone personally. 13 Reasons Why is a very difficult show to watch at times, but I believe it's extremely relevant and should be watched by everyone who is of age. It's a little too extreme to be shown in schools, but I believe it serves that same purpose while viewing. Even though it can be excessive at times, here is why I believe this show is superbly crafted. 

Based on the novel of the same name (which I haven't had the chance to read), I believe adaptations will always be best served in the form of a television series, as less will be left out. My main concern going in, was the fact that it may be too dark throughout the majority, leaving audiences too disturbed to continue. While there are certainly a few episodes that fit that description, I am glad that this show flashes back and forth between the happy and sad times fairly evenly. Every time this season delves into an overly somber portion of its story, it doesn't linger too much. This show always gives its audience a sense of hope moving forward. 

After committing suicide for unknown reasons, it is discovered by 13 of her schoolmates that she had recorded a tape for each of them, giving them an explanation as to why they had something to do with her horrible decision. Focussing mainly on Clay Jensen, who had the closest relations with her, the show slowly unravels the truth about why she did this terrible thing to herself. On the surface, this premise should turn most viewers off, but with the countless emotional twists at the end of every episode and a reveal that is one of the most eye-opening moments I have seen so far this year, this show is one that must be seen in my opinion. 

There are a few moments in the latter half of this season that will make you want to turn away, but the payoff is worth it, in a messed up sort of way. There is no way that any of the viewers will be wanting to see certain things come to fruition, but when they do, sadness will take you over, in the best way possible. This entire season is a lesson for many people, and while some viewers may be offended by the very idea of it, it's not trying to exploit this horrible occurrence that happens far too often, but shine a light for people that may be a little more oblivious than others. Does this show become too dark by the end? Yes, but it's all a part of being effective. If you are a viewer that can be up for anything, I believe this show demands your attention. 

In the end, '13 Reasons Why' is a show that fully explores the horror of suicide and how it can affect everyone in the process. It's an eye opener for multiple reasons and I truly feel that this is a show everyone should watch, sooner than later. I expertise an enormous amount of caution that a few episodes toward the end are extremely hard to digest, but the end result is emotionally riveting. Written incredibly well from beginning to end, having a terrific cast, and world class directors throughout each and every episode, '13 Reasons Why' is one of the best shows I've seen in a last few years. Again, it may be a little much for viewers that aren't exactly open for anything, but if you can have an open mind and see multiple sides to stories, then you may just end up loving this show just as much as I did. Highly recommended to a mature audience.

 

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