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Media may inaccurately portray, dramatize suicide
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NEW YORK — Though the association between fictional depictions of suicide and imitative self-harm is not new, recent trends in media content and viewer habits, specifically seen with the television phenomenon “13 Reasons Why,” has misrepresented and possibly sensationalized suicide to adolescents, according to a presentation at the American Psychiatric Association Annual Meeting.
Psychiatry residents from Rutgers New Jersey Medical School discussed how “13 Reasons Why,” a show released in March 2017 on Netflix about the suicide of a teenaged girl and the reasons she believed to be responsible for her decision to complete suicide, is representing mental health today.
Hanan Khairalla , MD, fourth-year resident, began speaking about the youth suicide rate. Specifically, she described youth suicide trends and factors associated with these trends, as well as how contagion theory applies to the media and how ’13 Reasons Why’ contributes to contagion.
“According to the CDC, suicide is the second leading cause of death among children between the ages of 10 to 24,” Khairalla said.
Based on data from high school students included the 2015 Youth Risk Behavior Survey, about 17.7% of participants seriously considered attempting suicide, 8.6% made at least one attempt and girls attempted suicide two times more often than boys (11.6% vs. 5.5%), Khairalla said in her presentation.
A theory for suicide in youth highlighted in the session was the contagion theory, which suggests that a social multiplier may amplify the effects or factors leading to suicidal signaling as a method of resolving conflict, according to Khairalla.
Next, Zain Khalid, MD, third-year resident, proposed that the main reason for collective anxiety surrounding “13 Reasons Why” has to do with suicide contagion.
He discussed the theories that may explain imitative suicide, including behavioral contagion theory and social learning theory, which is an especially common mentality acquired by teenagers.
“Most of the data has found a very strong correlation between nonfictional accounts of suicide — mostly news stories — sort of being responsible for imitation suicide attempts, with 69% having been cited in literature as being linked in some way to imitative effect,” Khalid said during his presentation. “There’s also a strong component on how those stories are being reported. Sensationalized, publicized accounts obviously have a higher correlation.”
Although existing studies have previously focused on how traditional media sources — print and television —affect suicidal behavior, the effects of newer media have not been widely investigated, he said.
‘We know that the teenagers are exposed to a much larger dose of media daily and much of that content is not being supervised, is through multiple platforms and it’s harder to regulate. So, that’s one aspect of it that needs attention,” Khalid said.
Content analysis
Teenagers are also much more susceptible and emotionally implosive, Khalid said, and much more likely to model their behavior than adults. He then walked the audience through a content analysis of “13 Reasons Why,” which he explains portrayed the suicide as a “revenge plot” and thus is particularly concerning to psychiatrists.
“It keeps us hooked, so it’s very compelling for teenagers as well as for adults,” Khalid said. “That kind of characterization of suicide is problematic, makes it an instrument for susceptible audiences and allows for it to potentially be a logical response to trauma.”
Khalid also noted that the adults on the show, including the school counsellor, are portrayed as unhelpful. The show casts mental health professionals as generally unhelpful in the minds of the primary audience (adolescents).
“Overall, the show’s depiction of suicide is constrained by the fact that it was generally meant for mass consumption, so it loses a lot of the complexity that appears in the issues of suicide, and requires more nuance and the consideration for more factors, especially mental health, which was generally disregarded for the purposes of the show,” he said.
Response
In response to “13 Reasons Why,” mental health organizations across the U.S. urged Netflix to include resources for mental illness and add trigger warnings, resident Kalliopi S. Nissirios, MD, explained.
For example, the American Academy of Child & Adolescent Psychiatry is sharing research on their website for families in response to the show, imploring Netflix to follow each episode with mental health resources and a reminder that depression and suicide can be treated by qualified mental health professionals, Nissirios said.
Netflix added trigger warnings for graphic scenes before the show’s two most graphic episodes plus a special following the show’s finale that discussed mental health, she said.
New changes resulting from a study conducted by Netflix that looked at the impact of the series included a warning video that will air at the start of the next season, which airs in May 2018, as well as more crisis information and resources on their site https://13reasonswhy.info/.
Attending physician Nicole A. Guanci, MD, from Psychiatric Emergency Services at Rutgers then discussed mental health’s role at the individual level and at the community/foundation level.
At the individual level, she recommended:
- advocating for resources and parental guidance;
- awareness;
- education and guidance to families, patients, teachers and providers;
- promoting screening in schools; and
- providing access to crisis services/evaluations.
At the community level, discussing appropriate post-suicide interventions (postvention) will be important, she noted.
“The main point of postvention is to provide support to survivors because they have a risk for suicide as well, especially in adolescents, schools and small communities,” Guanci said. – by Savannah Demko
References:
Guanci, NA.
Khairalla, H.
Khalid, Z.
Nissirios, KS. 13 Reasons Why Not: The role of suicide portrayal on suicide risk among young adults. Presented at: American Psychiatric Association Annual Meeting; May 5-9, 2018; New York.
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Barbara Stanley, PhD
The portrayal of the suicidal young woman in “13 Reasons Why” echoes how lay people often think about suicide in adolescents — that it is an understandable response to a stressful environment and that mental illness does not really play a significant role. When we hear reports about adolescents who have killed themselves, we often hear “oh he was great kid, he was regular, normal. He was a good student who received a bad grade on a test, he felt terrible and he killed himself.” This scenario gives a false impression of suicidal adolescents. When you look at psychological autopsy studies, about 90% of people who die by suicide have a major psychiatric illness. So, the idea that children without psychological problems who experience a stressor such as a poor grade or being teased would likely respond by killing themselves is not usually the case. It doesn’t happen like that. That may be the response if somebody has a pre-existing psychiatric illness or it could be that experiencing serious stressors kicks off psychiatric problems that then result in suicidality.
Another problematic issue with the portrayal of suicidal adolescents in the series is that it is premised on the idea that other people are to blame for someone decide to take his or her own life. It gives the idea that if only she did not do x or he did not do or say x, the suicide would not have occurred. It conveys the notion that suicide “makes sense” and is a rational decision if people treat you badly. This is problematic from two perspectives. One, for the suicidal person, it says that he or she is at the mercy of others and unable to control suicidal urges. “If people act bad towards me, I have to kill myself to escape.” This places responsibility for the suicidal act outside the suicidal individual. Instead, it should be “If people act bad to me, I have to find a way of coping; I have ways of reframing how I think about things, removing myself from the situation or changing things,” as opposed to “I’m at the mercy of other people.” I also think that there is another negative side to this “blame others” perspective for teens who have either had somebody in their environment kill themselves or make a serious suicide attempt. It could make them feel terribly guilty and responsible.
After the first season of the series was released, the number of online searches about suicide increased. It is important to remember what a profound (and potentially negative) impact a television series, although meant as entertainment, can have particularly on young people when they are still at a very impressionable age.
Perspective
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Jonathan B. Singer, PhD, LCSW
The residents were absolutely correct – suicide contagion is a real phenomenon which occurs almost exclusively with adolescents. A 2018 study suggests that there might be a contagion effect with suicidal ideation and attempt, not just death. Reyes-Portillo and colleagues found that adolescents who believed suicide ideation and attempts to be more widespread among peers were more likely to endorse suicide ideation and attempts. Although correlational, we know that following the release of 13 Reasons Why there was a spike in the number of people doing Google searches for “how do I kill myself” and calls to the National Suicide Prevention Lifeline. Forty years of research supports the idea that media reports can increase or decrease suicide risk for people already at risk for suicide.
The Ohio Suicide Reporting Guidelines and the Reporting on Suicide recommendations were developed for print media and expanded to include social media. There are no similar guidelines for creative endeavors, such as movies, TV shows, music, dance or visual art. Should there be? Sure. There’s no reason why a good filmmaker can’t creatively weave in warning signs for suicide or examples of helpful adults in a show where the main character kills herself. We don’t know what the response will be to Season 2, but an international coalition of suicide prevention and mental health organizations have developed a toolkit to help youth, parents and professionals address the content in Season 2. http://www.13reasonswhytoolkit.org/
References:
Reyes‐Portillo JA, et al. Suicide Life Threat Behav. 2018; doi:10.1111/sltb.12446.
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