New Show 13 Reasons Why Reinforces Dangerous Teen Suicide Myths
Teen suicide has been in the spotlight since the release of Netflix's controversial new show 13 Reasons Why, based on Jay Asher's popular book of the same name. Although the show's producers aimed to raise awareness about suicide, mental health professionals, parents, and school officials have argued that the show glamorizes suicide and does little to guide teens who are struggling with suicidal thoughts.
Suicide is the second-leading cause of death for youth aged 15–24 years and takes the lives of more teenagers and young adults than cancer, heart disease, diabetes, congenital birth defects, stroke, pneumonia, influenza, and chronic lung disease combined.
Madelyn Gould, PhD, MPH, professor of epidemiology in psychiatry at Columbia University in New York City, is an expert on teen suicide and the impact of the media on mental health. She sat down with Pablo Goldberg, MD, and Mirjana Domakonda, MD, both child psychiatrists at Columbia University, to discuss her concerns about the show and thoughts on what physicians need to know about how the show may be affecting their patients and their families.
Dangers of Depiction
Drs Goldberg and Domakonda: By now we know you have heard about the show 13 Reasons Why and have been part of the conversation surrounding its controversy. Have you seen the show; and, if so, how do you feel about it? Do you agree with the show's depiction of suicide?
Dr Gould: I first read the book several years ago on the urging, actually, of child psychiatrists in our division whose patients were starting to come in talking about it. When I read it then, I was really concerned. I then watched the series [based on it], and not only am I still concerned, but my concerns have amplified. The concerns I had with the book and the series are that they present teen suicide in a way that is likely to reinforce the behavior, and they also present help-seeking as a pointless endeavor, ultimately reducing the likelihood that a troubled young person will seek out an adult for help.
For at least a few decades, there has been extensive research on the impact of the media on subsequent deaths by suicide. Whether it is nonfictional stories about suicides or fictional depictions of suicide, how you present the information or the story can have a very different impact. If you sensationalize suicide and portray it as a behavior that yields rewards such as revenge, that has been associated with subsequent deaths by suicide. If you discuss suicide, but your protagonist does not engage in suicidal behavior but rather adaptive coping strategies, there is new research that shows that such stories yield a significant decrease in completed suicides. The site reportingonsuicide.org has a resource that anyone can download about how to safely portray suicide in the media. The media has a lot of power to influence young individuals, and I think in this case that the show's producers were careless with their representation of suicidal youth and their options.
Drs Goldberg and Domakonda: Why do you feel that 13 Reasons Why is particularly harmful for teens?
Dr Gould: The series does a number of things that are potentially harmful. First, as I mentioned, it presents help-seeking as a somewhat fruitless activity, painting both parents and school guidance counselors as useless. Second, Hannah is a very appealing character, and many teenagers can identify with her problems. By having her die by suicide, it not only reinforces the behavior but glamorizes suicide as a solution. The vast majority of young people who experience depression or similar life stressors do not go on to die by suicide. It is very unfortunate that the producers chose to show that the only way to cope with these problems and open up lines of communication is to kill yourself.
Revenge vs. Regret
Drs Goldberg and Domakonda: The show's producers, among them Selena Gomez, felt that it was important to show the graphic nature of Hannah's suicide to raise awareness about the issue. Do you agree? What do you think about how Hannah's suicide was depicted?
Dr Gould: I have heard people complain about the depiction of her death. I am not as much upset by its graphic nature as I am by the fact that it shows a romanticized version of suicide. Hannah's expression suggests some pain after she cuts herself, but it is short-lived, and the next scene is of her falling asleep peacefully in a warm bathtub. This image of the warm bathtub, usually associated with something soothing and comforting, is a far cry from our understanding of how suicide survivors usually feel in the moment—terrified, hysterical, and riddled with extreme regret.
Kevin Hines, who jumped from the Golden Gate Bridge in 2000, has since become a suicide prevention advocate and speaker and talks quite forthrightly about his mindset during his attempt. He says that as soon as he jumped, he realized that all of the problems he thought were so serious in his life—while they existed—were not nearly as serious as the major mistake he made by jumping off of the bridge. He talks to young audiences about that sense of regret and has been very influential in people thinking, "Oh, my God, I don't want to end my life thinking this is the biggest mistake I've made."
I would rather have seen Hannah do that—cut her wrist and go, "Oh, my God!" or try to stop the bleeding or get help. That way, even if she ultimately died, it would not have reinforced the idea of suicide as a peaceful way out of your problems.
I think that one of the worst parts of the show is that Hannah narrates the story after her death, which feeds into the fantasy that you can take revenge on people and see how events unfold after you die, like watching your own funeral. Regarding suicide prevention, I think it would have been much more effective for the producers to show Hannah survive her suicide attempt and re-emerge 20 years later as a famous poet. Or to show up at her high school reunion as someone famous—that would have been a better revenge.
Drs Goldberg and Domakonda: Art has always brought up similar examples of struggles and suicide. For instance, literature has the example of William Shakespeare's Romeo and Juliet or J. W. van Goethe's The Sorrows of Young Werther and innumerable movies and plays. Is 13 Reasons Why any different?
Dr Gould: It is very similar to The Sorrows of Young Werther. In fact, the impact that the media has on subsequent suicides is actually called the "Werther effect" after The Sorrows of Young Werther. The book was actually banned in Europe after publication because young men were dressing in the same style that was depicted in the book and dying in the same way, holding the book.
On the other hand, more recent research has shown that when the media portray suicide as something surmountable, and a suicidal person who, despite their depression, remains hopeful and engages in healthy coping strategies, youth may be more apt to do the same. This converse effect has been termed the "Papageno effect" after Mozart's The Magic Flute. There, the main character is suicidal but doesn't engage in suicidal behavior. That term was a spinoff of the "Werther effect." So overall, I do not think 13 Reasons Why is much different, although it is much more easily accessible.
Drs Goldberg and Domakonda: Should the book or the show be banned?
Dr Gould: I do not support banning literature. (As you know, The Sorrows of Young Werther was banned in Europe.) I think, as Americans, we are particularly averse to that idea, and it can be a slippery slope.
So given that we have the show, as physicians we now have an obligation to counterbalance whatever negative impact the series is likely to have by enhancing resources for teens, parents, schools, and providers. The goal now is for mental health professionals and others working with children and teens to have an armamentarium of resources for the populations who are bound to be affected by the series.
Discussing 13 Reasons Why with Patients
Drs Goldberg and Domakonda: How do you recommend that physicians approach the series, and its potential consequences, with their patients? Should physicians be preemptively discussing the show with children and teens?
Dr Gould: Yes. Primary care physicians should be proactive with the teens and parents in their practices and not wait for children and teens to bring it up. Just as they are hopefully doing some psychosocial assessments or screening for depression and suicidality, they should be inquisitive about what teens are watching.
I do not recommend bringing up 13 Reasons Why specifically because that may trigger otherwise unaware teens to seek out the show. But providers might ask about time spent on social media, popular TV shows, or the latest music trends. They could also ask their patients if they have seen anything lately that their peers are buzzing about, or if something has recently been very controversial or upsetting. This way physicians can explore what their patients are viewing in an unbiased manner and address things as they come up.
Drs Goldberg and Domakonda: Has the show resulted in suicide contagion—in other words, more adolescents attempting suicide as a direct result of the show?
Dr Gould: There have been decades of research describing contagion and the impact of the media on suicidal behavior. But I generally do not like the idea of "copycat" suicides because this term suggests that the show was the only cause of the suicide. We know that when people die by suicide, they typically have an underlying vulnerability or other mental illness. But a series like this can definitely give them the wrong impression about how to cope with the problems they have.
It is too early to tell if the show will have a direct impact, but I have heard from colleagues about teens binge-watching the show and presenting to the emergency department after a suicide attempt. Time will tell about the broader impact of this far-reaching series.
Drs Goldberg and Domakonda: Do you feel that the show improves or adds to the stigmatization of psychiatric illness? Do you think it distorts the scientific/real facts about mental illness?
Dr Gould: I think the series could add to the stigmatization of psychiatric illness by presenting youth suicide as an inevitable consequence of psychiatric problems. Yes, the rates of youth suicide have unfortunately been increasing over the years, but we know that the vast majority of adolescents with psychiatric illness do not engage in suicidal behavior. Furthermore, most adolescents who attempt suicide do not reattempt or commit suicide. The majority go on to recover but with help with proper treatment. Overall, the show brought awareness about suicide, but it did so in a way that reinforced stigma by not highlighting treatment and recovery.
The series also failed to show any coping strategies for dealing with bullying behavior, including cyberbullying. The association between cyberbullying and suicide is complicated. They are associated, but it is inaccurate to say that cyberbullying, or even sexual assault, is the only reason someone dies by suicide. If the show had changed the narrative in subtle ways and focused on recovery, it could have had the potential to do a lot of good. Suicide was presented as an option, and it should never be an option.
Real-World Resources for Suicide Prevention
Drs Goldberg and Domakonda: What would you tell parents whose teens are asking them to watch the show? Are there any resources you recommend?
Dr Gould: If I had my druthers, no one would be watching the show. That's how harmful I feel it could potentially be. That said, I know realistically teens will watch it, so I would prefer they watch it with parental supervision and guidance. But even that is not a perfect solution. Some teens who are not vulnerable will be able to watch the show and discuss it with their parents, including the issues of bullying, identifying suffering in others, and treating others well. But I am concerned about the children whose parents may not be emotionally available and who may struggle themselves with mental illness or suicidal thoughts.
If parents choose to watch the show with their teens, I recommend that they use the talking points that were developed by the JED Foundation and Suicide Awareness Voices of Education (SAVE) for guidance on how to address the shows' topics with teens.
Drs Goldberg and Domakonda: What can parents or primary care providers (PCPs) do if they think a teen is suffering?
Dr Gould: When it comes to psychiatric treatment, there is one ubiquitous, overwhelming barrier that spans across age, demographics, and cultural or socioeconomic differences: People want to handle problems on their own and often fail to recognize when they have a problem. Nor do they recognize the severity of their emotions when they are very anxious or depressed. They do not realize that their problem can be treated.
For that reason, it would be very hard for parents or PCPs to force teens into treatment (unless, of course, there are safety concerns). However, I do think it would be immensely helpful if PCPs and parents learned the basics of motivational interviewing so that they could explore what is going on in an impartial way and help the teen recognize that s/he needs help. Either way, they need to stay more engaged and discuss these things with teens to reduce the stigma around seeing a therapist or psychiatrist, if it is necessary.
Dr Gould's Recommended Resources
The Suicide Prevention Resource Center
Advises parents and provides guidance on how to address 13 Reasons Why with teens.
The American Foundation for Suicide Prevention
- Provides resources for people who feel suicidal or want to help someone else.
- Troubled youth and the adults who are worried about them can call the National Suicide Prevention Lifeline (1-800-273-TALK).
- Distressed youth can text the Crisis Text Line ("START" to 741-741) and immediately be connected to a crisis line via text, which is great for teens who don't want to speak on the phone.
New York Office of Mental Health
- Provides the "Safety Plan App," which allows users to create a personalized safety plan and call specific individuals when in crisis.
National Center for Telehealth and Technology
- Their "Virtual Hope Box" app allows users to upload photographs, songs, or media that remind them of positive thoughts and experiences. People can even choose to distract themselves with games, read inspirational quotes, and engage in deep breathing and progressive muscle relaxation to reduce stress and anxiety.
Substance Abuse and Mental Health Services Administration
- Offers an educational app to help provider assess suicide risk via the Suicide Prevention Five-Step Evaluation and Triage (SAFE-T) method. The app outlines the technique and provides case studies and conversation starters for providers working with suicidal patients.
Please note that all of these apps should only be used as adjuncts to treatment and should not take the place of a psychiatric evaluation or treatment.
 Web-based Injury Statistics Query and Reporting System (WISQARS). National Center for Injury Prevention and Control.
Centers for Disease Control and Prevention. http://www.cdc.gov/injury/wisqars/index.html. Medscape Psychiatry© 2017 WebMD, LLC.
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape. Cite this article: New Show 13 Reasons Why Reinforces Dangerous Teen Suicide Myths - Medscape - Jun 15, 2017.
This piece was originally published in Medscape Psychiatry and is the copyright of WebMD, LLC. It is reprinted here with permission from Medscape.
Drs. Madelyn Gould, Pablo Goldberg, and Mirjana Domakonda are within the Division of Child & Adolescent Psychiatry, Department of Psychiatry, at the Columbia University Medical Center. Dr. Gould is a Professor of Epidemiology in Psychiatry and director of the Community Suicide Prevention Group. Dr. Goldberg is an Associate Professor of Clinical Psychiatry and medical director of the Pediatric Anxiety and Mood Research Clinic. Dr. Domakonda is an NIMH T32 Postdoctoral Research Fellow.