Suicide on TV: minimising the risk to vulnerable viewersBMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3876 (Published 22 August 2017) Cite this as: BMJ 2017;358:j3876
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We would like to offer a different view on the recent debate on “13 Reasons Why”. In a recent editorial, your journal calls for regulation on the way that film and television companies depict suicide on screen. According to the authors of the article, the show violates guidelines for suicide portrayal in the media, by glamorising suicide, and portraying suicide as a solution to problems. In this way, the authors suggest the show inspires increased risk behaviours in some vulnerable young people.
There are several representations in cinema and literature. Do Thelma and Louise, The Virgin Suicides, Dead Poets Society pose a public health threat? The idea of censoring fiction is disturbing. Should we ban Romeo and Juliet, Madame Bovary, The Bell Jar and Anna Karenina because they might lead to an increase in suicide attempts and ideation? On the contrary, we advocate the moral merits of reading and watching fiction on suicide. Not to mention the lessening of our sense of alienation when we realise we are not alone in our experience of despair. Albert Camus claimed that suicide is a necessary response to a world which appears to be mute both on the question of existence and our search for meaning and purpose in the world.
Hannah Baker, the teenager at the heart of the drama, sends her classmates a series of tapes to set out her reasons for suicide. She chooses suicide in order to assert her autonomy, to reject her passivity and vulnerability. She feels she is able to vindicate her death through these tapes. The viewer is not called to sympathise for Hannah but instead invited to reflect on the problems of teenagers in the age of social media: diversity, conformity, the struggle to reach impossible standards by comparing themselves with others and how social media can be a terrible new vehicle for bullying and shaming.
Can any risk of self-harm be reduced by regulation or guidelines? Rather than sanitise the very fiction which addresses suicide and opens a dialogue with those most in need of it, we would do better by using its stories to demand the government invest more in mental health services for young people and information and counselling about self-harm and suicide in our educational system. Firstly, there is a lack of clear evidence for the influence of the media on self-harm, research reflects methodological and disciplinary inconsistencies. Even if we accept that media can have an effect, it is likely to be minimal and not a sufficient condition to drive people to commit suicide.
Secondly, the deepest and saddest experiences in life cannot be scrutinised solely through a scientific lens. Parents, educators and therapists cannot delegate their role to screenwriters or producers. They need to talk to children and young people openly not censor what they read or view. Perhaps the failure to confront our/their own and their children's existential difficulties is the reason Hannah’s character threw adults in the show into a panic.
Competing interests: No competing interests
It was a pleasure reading your article on 13 Reasons Why and its influence on young people. It was well-informed and backed up with crucial contextual facts that numerous internet thinkpieces on the series have negated to provide.
We had some thoughts on this article and would like to offer our opinions and suggestions on what could possibly be done and lobbied for now that the show has received so much attention.
Firstly, we of course acknowledge the increase in suicidal ideation in children and teens following 13 Reasons Why, as well as the fact that myriad factors such as social media, mobile phone use and access to the internet can influence it. However, while the sentiment of changing media recommendations to reduce the risk of copycat suicides is an understandable one, we don’t support the idea of total censorship. Creators of accurate and authentic media often write from experience, or at least research heavily into the subjects they want to depict. To restrict potentially essential new viewpoints on suicide and suicidal ideation on the basis that it could harm a minority of viewers would be the moral equivalent of censoring shows depicting drug use and manufacture as both are associated with similarly injurious outcomes (either directly or indirectly). A more nuanced position in this context would be one where suicides should be depicted to completion – if not as graphically as in 13 Reasons why – but also prevented in separate cases in the same show or film. Showing the benefit of halting such a drastic measure versus carrying it through, as was mentioned in your article under the Papageno effect (1), could similarly impact on young minds in a positive way. It would be interesting to see if suicidality in this age group declines following shows with this theme. Should this approach be encouraged, it would allow for both the creation of media on this essential hot-button topic as well as an increased awareness and discussion of the dire consequences of acting on suicidal impulses.
To enact this, we agree that the financiers of such media should improve assessments of the sensitive material they allow into the public domain. For instance, 13 Reasons Why was criticised for its failure to address Hannah’s mental health as part of its run, when it has been documented that treatable mental health conditions are highly prevalent in those with suicidal ideation (2,3). This oversight could well be dealt with in the show’s upcoming second season, but given Netflix’s recent promise to present original content at a rate of one new show per week, the sheer abundance of new material could well lead to a drop-off in quality control of individual products. Moreover, a bright and upbeat title sequence along with the partnership with Books on the Subway, a dramatic trailer and the creation of a page on the popular social media site Tumblr, suggests Netflix were deliberately targeting the show to younger viewers, who are often invariably more vulnerable. To press for more stringent recommendations to make sure these media giants carry out the appropriate assessments – as seems to be coming into play with the publication of updated WHO guidelines as you mentioned – would go a long way in promoting network responsibility over their material and in bringing sensitive and accurate depictions of suicide to the public eye.
We note at the beginning of each episode of 13 reasons Why there is a note encouraging viewers to call Samaritans helpline if they find themes distressing. It would be interesting to see if there was an increase in calls documented by Samaritans after the release of 13 Reasons Why and, if so, which age groups they were being contacted by most frequently. This could further inform us on whether viewers take heed of notes such as that put out by Samaritans and, if so, if there is a critical window of opportunity in which we can intervene to prevent suicides. This could also inform whether other shows with similar themes should have a note to alert viewers to the potentially distressing material.
Lastly, we feel the spectre of An Inspector Calls hangs over 13 Reasons Why far more heavily than has been reported. This story – published in the 1950s and a staple of teenage English GCSE education – addresses the suicide of a young woman and the ensuing familial conflict, a very similar concept to that of 13 Reasons Why and one which may well have had direct influences on some of the show’s most pivotal scenes. This suggests that educational bodies trust children and teens to grapple and come to terms with such a mature topic and is supported by the original novel 13 Reasons Why by Jay Asher being brought into American schools to educate young people against suicide (4). Visual media has a far greater public outreach than literature due to ease of access, and while it can be argued that watching such material reduces the influence of parents and teachers as teens often watch television alone, it would be false to claim that a) they learn of these sensitive matters in a vacuum and b) that they would learn better from the page than the screen. 13 Reasons Why’s TV adaptation could therefore become just as valuable an educational tool as An Inspector Calls. The combination of a popular TV phenomenon in conjunction with a deeper discussion of the mental health issues both in school and at home could foster an environment of openness and self-awareness, where young people can be honest about what they are going through and thus save many from the grief that accompanies suicide.
(1) Till B, Strauss M, Sonneck G, Niederkrotenthaler T. Determining the effects of films with suicidal content: a laboratory experiment. Br J Psychiatry 2015 Jul;207(1):72-78.
(2) Caldwell TM, Jorm AF, Dear KB. Suicide and mental health in rural, remote and metropolitan areas in Australia. Med J Aust 2004;181(7):10.
(3) Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry 2002;159(6):909-916.
(4) Brooks K. American Library Association Urges schools not To Remove '13 reasons Why'. 2017; Available at: http://www.huffingtonpost.com/entry/schools-remove-13-reasons-why_us_591.... Accessed 06/09, 2017.
Competing interests: No competing interests
Congratulations to the authors for their thoughtful and important editorial on the timely phenomenon of suicide and media portrayals of mental illness.
Criticisms of media portrayals such as 13 Reasons Why? focus on limited knowledge about mental illness, and poor insight, judgment, and moral decisions by creators. A logical solution, as the authors suggest, is to create policy, and better educate, monitor, and regulate media and creators to do the right thing, for better desired behaviors and outcomes when portraying suicide. But the entertainment industry and the media are driven by different motivations and incentives and owe little to public health. Furthermore, creators may genuinely believe they are doing more good than harm by portraying suicide to stimulate conversations and reduce avoidance and stigma of the topic, secondary to producing a smash hit entertainment series.
We believe the thinking and approach to the issue can be enhanced by reframing this as a human centered design challenge, in addition to a policy, monitoring regulatory problem. When conceptualized through the lens of human centered design, the media and audiences are given consideration as cultural and contextual variables or features that can be taken in to account and designed for or designed around for a desired outcome, rather than regulated. This may be even more useful in a rapidly changing social media landscape where patients, providers, and public are coming together in the same space. We have described human centered design as an overarching methodology and conceptual model for the design of anti-stigma interventions. https://link.springer.com/article/10.1007/s41347-016-0009-8
One of us (TU) applied this approach to the problem of suicide and media portrayals and produced a Reality TV style web-series Think You Can Shrink? https://www.youtube.com/user/KathyMorePls The design strategically and purposely leveraged the popularity of entertainment and power of media to encourage viewers to seek help for mental health problems, or encourage others to do so, in hopes of improved health outcomes for men. Actors portray an episode of suicidal depression, and other mental health problems. Everyday people who think they are good at giving advice (bartenders, hairdressers etc.) are the contestants. Through modeling viewers learn about depression, suicidal ideation, and how to communicate with a person to encourage them to get help. We designed for the protective and beneficial effects of narratives and media, highlighting depression as an illness, and encouraging empathy, and help seeking. This is in contrast to shows like 13 Reasons Why? that seem to portray suicide as a dramatized and perhaps romanticized solution to social environmental causal factors.
Our proof of concept study https://link.springer.com/article/10.1007/s10597-015-9910-4 demonstrated that the “edutainment” design works, with viewers finding the show entertaining, and more likely to seek help, or know what to say to someone who is suicidal after watching an episode.
In addition to policy efforts to regulate responsible portrayals, health promotion efforts may meet greater success using media as a powerful vehicle and tool to reduce and prevent suicide.
Thomas Ungar MD, MEd
Associate Professor, University of Toronto
Psychiatrist-in-Chief St. Michael’s Hospital Toronto, ON Canada
Stephanie Knaak, Ph.D
Mental Health Commission of Canada / Commission de la santé mentale du Canada
Ottawa, ON Canada
Cameron D. Norman Ph.D
Cense Research + Design, Toronto, Canada
Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
Competing interests: TU received a peer reviewed innovation grant funding from Movember Foundation Canada to produce Think You Can Shrink? and is the creator and owner of the intellectual property.