A Clashing of Worlds (and Perspectives) on the Problem of Suicide

Kurt Michael

In case you have not heard, the new series on Netflix, 13 Reasons Why (13RW), is generating considerable buzz in the popular media as well as in professional and scientific circles. 13RW is an adaptation of the novel 13 Reasons Why by Jay Asher. It tells the story of teenager Hannah Baker and her tragic spiral of despair, trauma, interpersonal isolation, and suicide thinking that culminates in the graphic and extended visual depiction of her suicide. Prior to Hannah’s death by suicide, she composes and disseminates 13 cassette tapes documenting her mostly retaliatory “reasons why.” The tapes are incisive yet poetic diatribes directed at those she believes contributed to her demise. The graphic suicide scene is equally sharp (pun intended), which is bookended by disturbing sequences of sexual assault and a steady stream of emotional cruelty and naïve neglect perpetrated by all.

It could be argued that 13RW is art imitating life and that there is much to like about the series, most notably that it has raised awareness about these important issues. Indeed, as the producers pointed out in an epilogue (13 Reasons Why: Beyond the Reasons), they not only intended to entertain the audience but they wanted to tell a story that “resonates with young people,” which they hoped would contribute to increased help-seeking behaviors. In fact, there is reason to be optimistic about this outcome. An article appeared in Washington Post this week where teens have responded to the buzz by sharing their personal stories in an attempt to reach other teens that are suffering in silence.

At the same time, there have been a number of valid criticisms of 13RW. Among the most commonly cited criticisms are that the displays of violence are gratuitous or that watching 13RW might trigger extreme distress, especially for those with undisclosed trauma or individuals who watch it alone without the ability to process the disturbing content. This criticism hit home for me as I wondered how my 17 year-old teenage daughter would react. Do I want her to watch it? It was hard for me to watch and I’m a fully trained, experienced, and licensed mental health professional — what about those who are not trained or experienced, or are teenagers in the midst of challenging life circumstances or have little in the form of current supports?

Yet, despite these criticisms, people are flocking to watch 13RW. The teens I work with daily seem to love it. Some teens have even accused my clinicians (many in their early 20’s) as being out of touch with teen culture, saying that as adults, we “don’t get it.” In fact, as an exemplar of a literal “piling on” to this so-called generation gap, my 24-year-old clinician was told that “24 is the new 40!” There have also been concerns expressed that the depiction of suicide might lead to contagion, a phenomenon that has been documented in the literature. A recent article was published by Scientific American and provides a credible summary of the facts.

So, in my view, the controversy with 13RW is essentially a clashing of worlds — the world of entertainment (and its predominant audience of teens) and the world of science and practice have very different perspectives on the problem of suicide. I’m not sure if these disparate worldviews will be married happily ever after, but who’s to say those from each perspective cannot find common ground in the service of something with life and death consequences? What follows are 4 recommendations to close the gap.

Recommendation #1: Know the science. The problem with suicide is significant and it’s getting worse.

According to the World Health Organization, over 800,000 people die by suicide each year. Based on estimates from the Centers for Disease Control and Prevention (CDC), suicide accounts for more years of life lost than any other disease save for heart disease and cancer1. For individuals between 10-24, suicide is the second leading cause of death2. Though in the U.S. suicide rates steadily declined between 1986 (12.5 per 100k) and 1999 (10.5 per 100k), the rates have steadily increased ever since, with the latest estimate being 13.0 per 100k in 2014, which represents a 24% increase since 19993.

During that same time period, the suicide rate among adolescent females has tripled (from 0.5 to 1.5 per 100k). Though the rates for this particular demographic are relatively rare, this type of spike cannot be ignored, especially when the risk for contagion is real and the options for intervention might be limited, especially in certain regions including remote and rural areas.

Recommendation #2: Acknowledge the good, the bad, and the ugly. Death by suicide is not pretty.

The impact and reach of 13RW is undeniable. It is now the most watched Netflix series in history and it has lapped the viewership of Orange is the New Black and House of Cards, combined. It is also an aesthetic powerhouse, full of beautiful people, perfect make-up, coiffed hair, impeccable diction, clever retorts, poetic rants, athletic prowess, and of course visible and artistically profound tattoos. Yet beneath the thin veneer of aesthetics lurks a pervasive darkness among the cast of characters. The issues depicted in 13RW are real. There are teens who are not honest with each other, parents who don’t see, predatory males who seek out and destroy anyone in their path, counselors who don’t counsel, and peers who don’t listen (or talk) to one another. The darkness includes depictions of the overuse of social media and how it is a perfect platform for 24/7 bullying, body shaming, rampant substance abuse, and a virtual lack of parental supervision.

Ironically, the most deliberate attempts to communicate honestly in 13RW occur when Hannah narrates her reasons for completing suicide after the fact, and she elects to do so on cassette tapes. Even after Hannah goes to the trouble to carefully document the “reasons why,” she packages her disclosures in a mostly inaccessible manner, perhaps as one last retaliatory gut punch. The problem here is that it seems so clean, so logical. Just as suicide is not pretty, it cannot be reduced down to a series of answers to the question of why. Nor can it be explained by a linear combination of solely external factors. Life is not binary and it is full of uncertainties and adversities. My comment here is not a criticism of 13RW per se, but rather a call to action to stop portraying the problem of suicide as a mystery to be solved. It is not a mystery. It is an epidemic of death that is getting worse. We need to pounce on every opportunity to talk about it in a way that honors truth, regardless of how messy, inconvenient, or uncertain.

Recommendation #3: Know the science of prevention and early intervention.

There is an abundance of effective suicide prevention programs available for use in a variety of contexts, including schools, and while 13RW provides some exposure to these resources, they did not go far enough. Thus, I strongly recommend that individuals or organizations that are motivated to take on this issue consult well-established clearinghouses and find programs that are feasible and affordable for dissemination in their local communities. A comprehensive list of resources can be found at http://www.sprc.org. Another lesser known but effective paradigm to prevent suicide is lethal means restriction. Interestingly, the focus of 13RW is on the “why” whereas a common sense approach to preventing death by suicide is limiting or restricting access to lethal means, otherwise known as the “how” of suicide.

There are several international examples where substantial reductions in suicides were achieved without ever considering the reasons why. The focus of the intervention was on how. Lubin et al.4 reported that approximately 90% of completed suicides among the Israeli Defense Force (IDF) were attributable to firearms. Prior to the intervention, soldiers were required to keep their weapons with them, including when they were on leave during weekends. In 2006, a policy change was instituted, requiring that military personnel leave their weapons on base when they went home for the weekends. According to data from the years 2003-2005 and 2007-2008, suicide rates on the weekends decreased by 40% after the policy change, yet there was no evidence of means substitution. During the same period, there was no change in the suicide rates during weekdays. These data, as well as other examples, document the impact of sensible public health approaches that must be considered as part of a comprehensive paradigm of suicide prevention.

There are other effective, uncomplicated, and low cost methods of prevention and early intervention, including the National Suicide Prevention Lifeline (1-800-273-8255). In fact, the American Rapper, Logic, produced a song titled 1-800-273-8255 and the lyrics are affirming of help-seeking. If efforts like these get traction, in part due to the controversy sparked by 13RW, then this would go a long way to help close the gap between the entertainment and healthcare and science worlds.

Another really important resource that will surely help to close the gap is Crisis Text Line (CTL; Text HELLO to 741741). Given that texting is now the preferred method of communication about very serious matters, teens were already moving in this direction prior to 13RW. I have communicated informally with CTL staff who have confirmed that a great deal of recent text traffic has centered on the topic of 13RW. The jury is out on whether these trends are positive or not. However, what is not in question is the fact that you cannot oversell the value of providing outlets for disclosure and outreach. I urge the producers of 13RW to do more, to provide more of these resources at the bottom of every screen, to provide similar help-seeking messages before and after each episode, and not to wait until the epilogue to emphasize these opportunities for prevention and intervention. I think it’s irresponsible to depict such serious material over multiple episodes, profit from it, and then neglect to provide reliable public health and mental health resources at the same time. This should not be an afterthought, and it certainly cannot be that expensive to beef up exposure to these resources before, during, and after each episode.

Recommendation #4: Know the science of practice. Suicidality can be treated successfully.

Although a comprehensive summary of effective treatments for suicidality is well beyond the scope of this article, I want to emphasize a few points. First, the stereotypic assumption is that being suicidal requires inpatient hospitalization. In a study I published with my colleagues, we found that after intervening 68 times with adolescents who were referred for a suicide assessment, only about 12% were subsequently hospitalized5. Thus, not only is the stereotype inaccurate, there is evidence that hospitalization can actually increase the risk of suicide in some instances.

Part of the problem here centers on what happens after a person is hospitalized and the time immediately after discharge. As clinicians we can sometimes be lulled into a false sense of security that as long as the acute crisis is dealt with, we are out of the woods. Regrettably this is often not true. What is true is that gaps in the continuum of care for suicidal individuals can and should be addressed, including providing for regular follow-ups, safety checks, and offers of tangible support. Indeed, there have been studies that have shown immediate referral to outpatient treatment, such as cognitive-behavioral therapy (CBT) actually lowers the risk of future suicide attempts when compared to usual care or hospitalization for suicidal individuals (e.g., Greenfield et al., 20026).

Similarly, in addition to CBT, there are very focused, intensive, and effective interventions for suicidality. Among the options with solid evidence of effectiveness are the Collaborative Assessment and Management of Suicidality (CAMS; www.cams-care.com) and Dialectical Behavior Therapy (DBT). I certainly don’t expect individuals to commit these resources to memory but it would sure be helpful for consumers of 13RW to know the basics of what to listen for in terms of effective intervention. The cost of information dissemination as part of the 13RW series pales in comparison to its potential impact on the problem of suicide. It is certainly not too late to do more to bridge the gap. Moreover, a second season of 13RW was just announced, so be prepared for another wave of reactions.

In closing, the entertainment, science, and practice worlds need to be more strategic and less discordant in the way they communicate with one another in the service of preventing death by suicide. A life (or lives) might depend on it.

Note: Credit for some of the ideas and anecdotes in this article goes to hardworking clinicians whom I am blessed to consider colleagues, including: Whitney Van Sant, Morgan Brazille, JP Jameson, Jennifer Wandler, Elizabeth Capps, Stephanie Moss, Rafaella Sale, Carissa Orlando, Cameron Massey, Marisa Schorr, Kelsey Toomey, Anne Stevens, Heidi Campbell, Lauren Renkert, Jan Stone, Jon Winek, Tara Miller, Mike Tasso, Annette Bednosky, Amanda Hipp, Leigh Lyall, Kellia Riddle, Amy Smith, Lauren Mullis, Rebecca Schenk, Rebekah Smith, Holly Hauser, Wayne Eberle, Jason Krider, Jamie Little, Michael Murphy, Kyle Austin, Theresa Egan, Abby Albright, Crystal Thornhill, Krystal Trout, Jackie Belhumeur, Stephanie Smith, Melanie Rosen, Alex Kirk, Stephanie Lichiello, Kerry Kelso, Daniel George, Kelsey Thomas, Chelsea Price, Kara Visser, and Angela Quick.

Show 6 footnotes

  1. Centers for Disease Control and Prevention (2013). Mental health surveillance among children: United States, 2005-2011. Morbidity and Mortality Weekly Report, 2, 16-17.
  2. Centers for Disease Control and Prevention (2014). 10 leading causes of death by age group, United States – 2014. Available at: https://www.cdc.gov/injury/images/
  3. Centers for Disease Control and Prevention (2016). Youth risk behavior surveillance – United States, 2015. Morbidity and Mortality Weekly Report, 6, 10-13.
  4. Lubin, G., Werbeloff, N., Halperin, D., Shmushkevitch, M., Weiser, M., & Knobler, H. (2010). Decrease in suicide rates after a change of policy reducing access to firearms in adolescents: A naturalistic epidemiological study. Suicide and Life-Threatening Behavior, 40(5), 421-424.
  5. Michael, K.D., Jameson, JP, Sale, R., Orlando, C., Schorr, M., Brazille, M., Stevens, A., & Massey, C. (2015). A revision and extension of the Prevention of Escalating Adolescent Crisis Events (PEACE) protocol. Children and Youth Services Review, 59, 57-62.
  6. Greenfield, B., Larson, C., Hechtman, L., Rousseau, C., & Platt, R. (2002). A rapid-response outpatient model for reducing hospitalization rates among suicidal adolescents. Psychiatric Services, 53, 1574–1579.

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  1. Kurt,

    suicidality is a SYMPTOM. It’s not the real issue to ‘be treated.’ Surely you understand that unless you’ve bought into the biological model of the brain. I do hope you were simply careless with your word choice though being an expert on suicidality and the entire tone of this article make me wonder.

    As someone who has struggled with suicidality for 30 years, I understand how it works in me pretty well. And after 8000+ pages of journaling, I know exactly WHEN it began and WHY it began and continues. And as long as forced hospitalizations are on the table, I would never, ever seek help…besides no one can fix the causes of my symptoms other than me and my wife.

    I’m all for helping teens not make an overwrought, emotional choice when their brains are not fully developed. Life for them hinges on things that, with perspective, are not nearly so important. And again it’s great that the IDF dropped suicide rates by 40% with one small change in policy. But you admit these don’t address the real issues driving people to the ultimate solution to their pain, isolation and hopelessness. Until the life experiences behind those feelings are addressed, everything else is but a short term solution.

  2. While I appreciate the important emphasis on compassion for suicidal teens, I’m really not sure what to say about this article. While I agree that putting resource numbers at the end of each episode is a good idea, I’m kind of astounded at how badly the author appears to miss the point of the series. The comments about not needing to understand the “why” and simply removing “means” seem to invalidate the important issues that the series raises, namely the importance of understanding the context in which suicides occur. The whole point of the series is to show that there ARE whys and that many people COULD have done something about the situation but did not! It also emphasizes that systemic changes are needed, as administrators and the counselor don’t appear to understand that bullying is rampant in the school, and the kids are unable/unwilling to trust the adults BECAUSE THE ADULTS HAVE NOT SHOWN THEMSELVES TO BE TRUSTWORTHY! The counselor and assistant principal had Clay on the verge of talking about the whole situation, but their authoritarian and accusatory approach caused him to clam up. The similarities to the situation in the “mental health” system can’t be missed by anyone who has been on the receiving end of “services.”

    The incredible challenges involved in reporting sexual assault are also highlighted, and contributed very significantly to Hannah giving up. One very good way to reduce suicides is to make it easier and less traumatic to report events like sexual assault and domestic abuse, but the author fails to even mention these points in the article.

    From the article: “Part of the problem here centers on what happens after a person is hospitalized and the time immediately after discharge. As clinicians we can sometimes be lulled into a false sense of security that as long as the acute crisis is dealt with, we are out of the woods. Regrettably this is often not true.” This suggests that suicidal feelings somehow “sneak up” on clinicians because the clinicians are overconfident that “the crisis is over.” This ignores more significant reasons why suicide happens AFTER hospitalization. First, hospitalizations are TRAUMATIC for most clients, especially if they are enforced or not entirely voluntary. This trauma is denied or minimized, just as the administrators at Hannah’s school deny or minimize the enormous reality of bullying in their school. As a result, no one talks about this to clients, nor acknowledges the feelings of powerlessness that often occur in the context of a psych ward. Additionally, many clients describe being unwilling to communicate their feelings to their professional support people after being hospitalized against their will, because they are afraid to be hospitalized and traumatized yet again.

    Second, the main thing that happens during psych hospitalization is that the client is tried out on a new drug regimen. It is well established at this point that antidepressants and antipsychotics, the two most common prescriptions given in psych wards, both can induce suicidal ideation or action. To ignore this important variable shows a limited commitment to scientific reality.

    To talk about “suicide prevention” outside of the context of why people kill themselves seems bizarre and disconnected. In fact, it seems to reflect the same kind of disconnectedness that kept Hannah and Clay and the other students from reaching out for help. I think the author does a great disservice to both clients and professionals by suggesting that preventing the ACT of suicide is more important than preventing suicide by understanding our clients and by revising and reforming our institutions so that trauma is less common and easier to talk about with authorities and less traumatic to resolve.

    — Steve

      • In that regard, shouldn’t the series be lauded for not even bringing “mental illness” into it – instead focusing on feelings, events and discussion of those conflicts?

        It’s not my cuppa tea, and I cringe at the thought of such dark media infiltrating the homes of vulnerable teenagers – but – at least they didn’t focus on the “disease” the “treatment” or “she went off her meds” as is so common in mainstream TV today.

        • Teens and young twenties I’ve talked to about it have said that they find it kind of insulting that adults argue they can’t “deal with” this kind of material – they say they ARE dealing with it and it feels like someone’s finally TALKING about the realities they face. I would agree that a person who is already feeling suicidal, especially if they are a sexual assault victim, might need to be very careful about whether they want to watch it or not, but it is rare that teens get to hear something in a teen voice that is so real and relatable for them. That’s why it’s so popular. And you’re right, the absence of any focus on “mental illness” is one of the series’ primary strengths – it focuses on the fact that there ARE reasons for feeling suicidal and it’s NOT abnormal and that there are THINGS THAT ALL OF US CAN DO ABOUT IT! To me, that was the most exciting and positive message – that any of the 13 people could have made a difference in her mind, and perhaps if only one of them made a different choice, she’d still be alive. It was tragic on the one hand, but on the other, it ended with a message of hope, which is more than I can say for most shows addressing “mental health issues” like suicide.

    • You seem to be vastly generalizing the “trauma” of hospitalization. Having placed teens, both voluntarily and involuntarily, in psychiatric facilities, I can tell you that the “trauma of hospitalization” to which you repeatedly refer is a rare phenomenon. Most clients experience a sense of relief, they relish the “powerlessness” to which you refer. I think you’re forgetting that our decision-making is impacted by our mental states and vice versa. Having decisions made for us, having a routine, and having order allows us to put down what, by the time hospitalization is warranted, is often a very heavy and unsustainable pattern of self-destructive or self-sabotaging behaviors.

      Next, the idea that it is “well documented” that antidepressants and antipsychotics can induce suicidal ideation or action is once again a broad, overreaching generalization. Yes, SSRIs can induce mania in persons with bi-polar disorders, which may in turn lead to an increase in suicidal ideation, but you’re hanging on to old data with regard to SSRI induced teen suicide. The FDA review that led to the black box warning was amazingly small, 2200 cases, and its results were generalized far beyond what they should have been given the limitations of the review. Subsequent studies have analyzed upwards of 60,000 cases and found no significant increase in SI after beginning SSRIs. Research has also shown a marked decrease in completed teen suicides where SSRIs are more readily prescribed to teens.

      Lastly, I’m not sure if you’re a clinician or not… maybe you’re new to the field, but if you don’t understand why addressing the ACT of suicide must take precedence, I’m just not sure what to tell you. There are, at times, alternatives to hospitalization… and we use these when they’re available. If you have, for example, a family who you know with certainty will provide supervision and secure the home of lethal objects (pills, knives, etc), then yes, you can contract with that family to ensure the safety of their teen. But this is seldom the case. So if hospitalization is what I have at my disposal to keep someone safe, that’s what I’ll use. When someone is actively suicidal, I’m not going to try “understanding our clients and by revising and reforming our institutions so that trauma is less common and easier to talk about with authorities and less traumatic to resolve”… I’m going to be solely focused on preventing that person’s death. Your attack on this author is completely baseless.

      • Perhaps you misunderstand me. I have helped run a suicide hotline and have done involuntary hospitalization evaluations. I’ve placed many people into involuntary holds, directly or indirectly, and have also intervened with many, many more suicidal people and prevented many, many hospitalization with on-site or telephone crisis interventions. I have also spoken with many folks who have been hospitalized after the fact. To suggest that traumatization by involuntary hospitalization is rare suggests a Pollyanna view of reality. Sure, clients in the hospital often express relief that they didn’t end up killing themselves, but they also learn very quickly that telling the staff you’re pissed about how the situation was handled or that you feel powerless is both pointless and dangerous. I don’t know if you watched the show in question, but you ought to, and you ought to look at how often the teens tell the staff and/or their parents and even each other that everything is “fine” and there are no problems, even though they are seething with discontent, fear and grief. You have to develop sufficient trust for people to tell you their true feelings. I am very good at doing so, and I guarantee you that feeling traumatized is far from a rare thing.

        As for suicidality from antidepressants and antipsychotics, gosh, there are warnings on the labels to this extent. Not sure how you can actually argue that point. New evidence more recently has shown rather conclusively that these effects are not limited to teens and young adults. Aggression is also sometimes a consequence of messing with the serotonergic system, as is listed on the label of all of these drugs, and as a recent MIA article has documented.

        Naturally, preventing immediate suicide IS important and is the priority in a crisis situation. That was not my point. My point is that IN THE CONTEXT OF THIS SHOW, talking about methods to reduce the likelihood of suicide without looking at the causes misses the entire point of the production. The point is, people had MANY opportunities to intervene and perhaps prevent this suicide LONG before the crisis situation ever began to arise. This is true in many, many situations and the main intervention is to have people care about you and have the guts to stand up to bullying, sexual assault, and harassment instead of keeping quiet until the victim can’t stand it any more.

        The secondary lesson also appears to bypass you completely based on your comments. The show demonstrates how our INSTITUTIONS, parents, police, schools, and the mental health system itself, fail to create a safe place where talking about the above issues is realistic. To give you an illustration, a recent survey of kids in residential treatment centers showed that they revealed significant trauma histories to complete strangers in 80% of the cases. Oddly, only 20% of the cases had traumatic events documented in the file! So at least 60% of the kids were willing to share their abuse stories with TOTAL STRANGERS but were either never asked by staff, didn’t feel safe telling them, or worse yet, told staff who didn’t feel the information was significant enough to include in their files.

        Perhaps you have to watch the series to know what I’m talking about. Perhaps you need to step down from your professional pedestal and actually meet your clients where they live. Maybe you should ask a couple to DESCRIBE what being taken into custody was like, rather than asking them if they are grateful to be in the hospital. You might be surprised how many people appreciate that someone cared enough to try and stop them, but most definitely did NOT appreciate the violence and invalidation involved in being taken into custody. I’m sure you’ll hear from many of our regular posters on this point.

        Lastly, your comments on how benign the SSRIs have since been found to be are questionable to me and lack any reference. It might help if you can provide links to these statements.

        Appreciate your candor in responding, but you might want to avoid questioning my experience and credentials before you know anything about me. It is that kind of approach that encourages people to say they feel fine when they really don’t.

        — Steve

        • I have often sat with people who are psychiatric patients and within an hour they will tell me about thier truamatic histories. I ask them if the services know about this and they say no. I ask them how long they have been in services and they say 10 – 20 – 30 years. I ask why they do not tell the services and they say in so many words they do not trust them and they are not worth telling.

          So I completly agree with you about how service users so often see staff, and quite rightly so in my opinion, as untrustworthy

          • And we have to remember that it takes only one or two bad experiences to shut down trust in service providers for the long term. Even if 80% of providers are safe, the client doesn’t know which are dangerous until they open up and potentially get hurt. A bad experience often means no one else gets a chance. I always thank clients who extend their trust because I understand the risk the are taking. All clinicians should learn to appreciate how precious and delicate that trust is for the vast majority of clients.

        • Regarding the trauma of hospitalization. Steve, you say, “To suggest that traumatization by involuntary hospitalization is rare suggests a Pollyanna view of reality. Sure, clients in the hospital often express relief that they didn’t end up killing themselves, but they also learn very quickly that telling the staff you’re pissed about how the situation was handled or that you feel powerless is both pointless and dangerous.”

          And I can think of more than a few cases – where the FAILURE of suicide is a heavy, traumatic burden on the person who experienced it – and finds themselves corralled, restrained, searched, locked up, drugged.

          Heaping trauma upon trauma.

          There are a few who find hospital a relief when in this sort of crisis. There are even some who get addicted to being cared for, comforted by being numbed to their pain. But on the whole I’m with you, and put hospital in the “increase of trauma” category.

          • I had forgotten that point, though I have observed it – there is a great deal of shame in “failing” to kill oneself, and the hospital venue TOTALLY reinforces this, with everything from condescending pity to messages that the client’s “disease” made them do it, implying they are “wrong” for wanting to kill themselves. I wonder how much that contributes to the huge increase in suicides AFTER hospitalization. The whole thing is humiliating, especially if it’s involuntary, and no one seems to be willing to simply acknowledge that to the clients.

            Thanks for sharing and reminding me of that important perspective!

      • There is always trauma. I was incarcerated twice. The only lesson I learned is never ever under any circumstance tell anyone you feel depressed. I was not even suicidal the second time. I was upset after being fired from my job. Only after being taken against my will did I even consider maybe it was time for me to give up on life since clearly I am just a burden to everyone around me. Every single person that was stuck in the waiting room was trying to talk their way out of the hospital. Not because they wanted to go hurt themselves, but because it was a situation worse than prison. Let me repeat again- worse than prison. And do you know why I would have rather been in country? At least there I don’t have to pay $1,900 for my stay. I wish there were statistics on how many suicides were caused by “good Samaritans”. You have probably killed more people than you saved.

          • I had a nightmare lastnight in which I thought people were in my room trying to abduct me. I tried, and may have succeeded in shouting out, “HELP.”

            I hope I didn’t disturb the neighbours.

            I think one of the triggers was reading the comments on this article. It bought home to me the trauma of forced hospitalisation.

      • Dickson

        It’s very obvious that you’ve never been held in a psychiatric institution. You make claims that you know very little or nothing about. Why is it that statics show that you’re more likely to try to kill yourself AFTER being “hospitalized” than before?

        Knowing why a person tried to kill themselves or wants to kill themselves is the first stop in helping people deal with all of this. Locking them up in the “hospital” does very little to nothing in helping people because all they do is pump you full of drugs that zombify you; they do not get to the bottom of the issue or issues causing the feelings. You are only trying to treat the symptoms; you are not dealing with the issues.

        The attitude that you exhibit here is exactly the reason that few people approach anyone in the system for help when they’re feeling hopeless and down and out.

  3. “The problem here is that it seems so clean, so logical. Just as suicide is not pretty, it cannot be reduced down to a series of answers to the question of why. Nor can it be explained by a linear combination of solely external factors. Life is not binary and it is full of uncertainties and adversities.”

    In those four sentences, you’ve presented the community ethos that killed “Hannah” and thousands of other real people of all ages, every single year. Spotting limits on the validity of the esoteric is one of your jobs as a clinician. Today, you have miserably failed at it. Many things in life really ARE very, very simple. If it were extraordinarily complicated to merely LIVE, our species would have killed itself off before now. When you cut through all the PC bullshit, the truth is STILL there on Netflix for all to see: Hannah was killed by the power players in her life (boys, parents, quacks, bullies) who had sapped her will to live and, thus, CHOSE to become her executioners.

    Suicide is not supposed to be “pretty”. That’s the one moment in life, when YOU ARE DONE WITH TRYING TO APPEASE THE PEOPLE WHOSE APPRAISAL OF BEAUTY IS DESTRUCTIVE AND LETHAL. In “Hannah’s” case, suicide met only two vital needs: 1) to leave a world that would never again be humane and 2) to bring her perpetrators to justice. On top of attracting a MASSIVE mainstream audience, 13RW has now become a part of both the Mad Rights canon and the Women’s Rights canon. “Hannah’s” seized her vindication in death, but she’s got it now, and it’s here to stay. So, needless to say, her suicide was a monumental success. Most of us will never be that fortunate.

    Until now, suicide was accompanied by the HIGH likelihood that one’s story would be buried along with them. Their notes would be thrown out, and their last conversations would be concealed by their executioners, soon to forgotten. But, from here on out, the dead will speak among us for all time – in sound and living color, no matter where in the world we go. In times past, we couldn’t know why people committed suicide BECAUSE THEIR EXECUTIONERS GAGGED THEM FROM BEYOND THE GRAVE. By insisting that “Hannah’s” suicide is incomprehensible, you’re clinging “bitterly” to either one of two fallacies: 1) audio tapes are “inaccessible” (To who? Cave dwellers?) or 2) “Hannah” was “too sick” to understand and condemn the people who slaughtered her. So, which is it? I’m guessing #2.

  4. Kurt,
    Thanks for this interesting article. I hope you won’t take criticisms of your ideas too hard. To me, you appear to have particular ways of thinking about helping someone as “treatment”, of interventions as “brands” of therapy, that might be (unintentionally) offputting to many people here who are heavily against mainstream psychological ideas and practices. However, I wish more people would comment on how you included interesting facts, insights, and ideas about suicidality, even if you operate with a framework of thinking different from one’s own. I think we should not judge people so quickly for what they say or how they say it, and understand first. When we judge someone, we do not learn.

  5. Thank you Steve, J, and others for your insightful critique of the shortcomings and problems with this blog.

    Kurt Michael, you said: ” Some teens have even accused my clinicians (many in their early 20’s) as being out of touch with teen culture, saying that as adults, we “don’t get it.” In fact, as an exemplar of a literal “piling on” to this so-called generation gap, my 24-year-old clinician was told that “24 is the new 40!”

    Have you ever considered the possibility that the huge “gap” that some of the teens are describing about your clinicians may have absolutely NOTHING to do with age. It may instead have EVERYTHING TO DO WITH THE TYPE AND CONTENT OF THE EDUCATION THAT CURRENT STUDENTS ARE RECEIVING BEFORE THEY ENTER TODAY’S “MENTAL HEALTH” FIELD.

    Over the past 4 decades there has been a complete “take over” (in both education and practice) by the Biological Psychiatry “Disease”/Drug based Medical Model of so-called “treatment. The collusion, at the highest levels, between Big Pharma, the American Psychiatric Association (APA), and the leaders of academia, has led to a consolidated shift in the way psychological duress is understood in today’s world AND how caregivers are taught AND directed to provide support and care.

    Today’s students are thoroughly indoctrinated in a pseudo-scientific paradigm dictated by the outlook and practice of Biological Psychiatry, where the essential content is nothing more than a series of “genetic theories of original sin.”

    Students are directed AWAY from looking at what is wrong in our surrounding environment, and forced to focus on defective genes, brain “diseases,” and the “magic bullets” of mind altering psychiatric drugs that are alleged to correct mythical “chemical imbalances” in the brain.

    Even in those educational programs where students MIGHT be exposed to alternatives approaches (other then the dominant Medical Model) we cannot underestimate the overwhelming influence that the hundreds of billions of dollars spent by Big Pharma and the APA in its massive PR campaign over the past 4 decades, has had on influencing the thinking of the American public.

    It is NOT A MYSTERY why young caregivers actively working in today’s “mental health” system are completely unable to effectively reach out and connect to teenagers who are only a few years different in age.

    Suicide is NOT a mystery, nor are the solutions to this crisis that difficult to understand. There must be major Revolutionary type institutional changes at all levels in our society. But the first thing that needs to happen is that We ALL need our brains “washed” thoroughly from the harmful AND deadly way of thinking and “treating” people promoted by Biological Psychiatry.


  6. It’s not that mature adult leadership for teenagers would be nice, it is essential. The premise that if only kids would be nicer to each other, you can avert tragedy, is flawed to begin with. What I think should come out of a story like this is that what is considered normal for adolescents is in fact a complete aberration of human needs. You can’t combine immature individuals together and expect mature results. And yet for typical teenagers, they are left to their own devices, because adults, the parents, have lost their instinct to assume the role they should have.

    Metal health professionals typically take a mechanical approach to emotional needs. It doesn’t work that well. A child needs an emotionally responsive go to person who has a stake in the child’s life. A child needs to have power in this relationship so he can share his inside world of feelings with a person of some importance. This is foundational, what is needed without question, in every life.

    • You captured what I wanted to say in many fewer words. The teens’ behavior is a response to the structure provided (or not provided) by the responsible adults. Those setting up the system are responsible for making sure it works, not those who are powerless participants. Thanks for your comments!

  7. Kurt

    Thanks for writing here at MIA and participating in a difficult discussion.

    One important thing to point out in this discussion, is that in today’s world (when looking at power relationships), Psychiatry is the only other institution in our society that has as much power as the U.S. President and the Executive Branch of government.

    After just a 5 minute discussion with a “mental health” worker or family member, a psychiatrist can completely strip away a person’s Constitutional Right to freedom with a simple signature of a pen. With this signature any person DEEMED “a threat to themselves or others” can be forcibly incarcerated and drugged (some would say “mind raped”) in a psychiatric hospital.

    There is accumulating evidence that it is these kinds of experiences of trauma (the use of ‘FORCE”) that are a major contributing factor to the rise in suicide in this country.

    Kurt, I challenge you to read and contemplate the arguments made in the blog I wrote for MIA a few years ago titled: “May the ‘Force’ NEVER EVER Be With You: The Case for Abolition.” Here is the link: https://www.madinamerica.com/2014/10/may-force-never-ever-case-abolition/

    Respectfully, Richard

    • And I would add the point that the above link to my past blog on the use of ‘FORCE’ has one of the richest and most in depth discussions of this topic from every imaginable angle. Kurt, I would hope you might see the value of using this blog AND following discussion with all of your students.


  8. I think availability of methods to commit suicide are an important factor in reducing the incidence. The availability of certain drugs and of firearms are two things to consider on both a societal and household level.

    I can’t find information on where restricting which drugs are sold over the counter by country related to suicide rate but it would be interesting to investigate. I have not looked up how the availability of guns is correlated to suicide rate either but as the gun violence rate is related to availability of guns I suspect suicide rates are also related.

  9. I wish Mad In America would make up their mind whose side they’re actually on – the person being “treated” or the institution of psychiatry. This is usually an affirming site but Sometimes, with articles such as this one, I can no longer tell.

    Thank, Steve, for your insightful pushback.

    I’m pretty appalled by the tone of this article – actually, I find it rather tone deaf. I certainly to would never suggest to a fellow patient or ex-patient that they were honest with anyone about their symptoms. Support is what people need, not drugs and lockup.

    • I would have to amend that to say I’d suggest being VERY CAREFUL about whom they might trust. There are definitely a few diamonds in the rough, and clients/patients/inmates are sometimes fortunate to find them, but I would most definitely counsel them that sharing in a hospital could be dangerous and to be very selective about whom they might trust. In fact, I’d tend to apply that to any counselor/social worker/mental health professional in any role. A lot of damage can be done by trusting the wrong person with sensitive information, and sometimes the very best thing we can teach our clients is how to figure out whom they can and cannot trust.

    • @kindredspirit: Obviously, I can’t really speak for the whole MiA staff, but I think they’re TRYING to be “neutral”.
      The overwhelming evidence says psychiatry is a pseudoscience, a drug racket, and a means of social control. It’s 21st century Phrenology, with neuro-toxins. As a survivor of forced drugging, Mia lets me tell my story here, write my TRUTH, give my TESTIMONY. And, after all, it’s not you and me who needs to be convinced. OUR TRUTH needs to be told to other doctors, to psychiatry itself, and to the larger society which has been so brainwashed by PhRMA, and greed. So yeah, I get what you mean about “whose side” we’re on, but really, we need to stop “taking sides”, and making “sides”. That only leads to conflict, which is unhealthy. I’d like to see psychiatry replaced with healthy psychology, and psychopharamacology. If we have to have drugs, I’d like to see them used HONESTLY, with FULLY INFORMED CONSENT. Right now, psychiatry and the system use FORCE, COERCION, and UN-informed consent. Getting us emotionally upset, and “appalled”, is one of the ways they control us. I’m trying to educate and LIBERATE us. I and we need all the kindred spirits we can get. I’m glad you’re one of them, and I hope this helps you feel a little less “palled”!….~B./

      • I think the MIA staff is creating a safe space for discussion, or trying to. The only “side” I think MIA is on is that the current way of doing things doesn’t work and needs to be “rethought.” And I agree, more “sides” means less cooperation and less success. We should be emphasizing what we agree on, and your postulates are a great starting point.

  10. Kurt,

    I have admittedly only read through your blog and then skimmed the comments, so I may be missing something already said in the subsequent dialogue, but I would like to point out that you have linked to a ‘suicide prevention’ resource that promotes products that are – in some cases – pharmaceutically funded. For example, it includes the SOS program about which I wrote a blog (https://www.madinamerica.com/2016/01/middle-school-invasion-when-the-pharmaceutical-companies-come-to-town/) when they tried to peddle it to my son at his middle school.

    While I understand what you’re getting at with some of what you write, I found myself reacting with concern to a number of points. For example, this emphasis on restriction of means… It reminds me of a suicide and self-injury training I attended earlier this week.. One (of many of) the most disturbing moments was when the trainer said that – after a particular suicide – he restricted anyone receiving services at the org where he worked from living in an apartment that was any higher than the second floor. Great. (Not really.)

    I’m also having trouble getting past your statements about people basically being happy to be locked up and become powerless… I mean, sure, some people experience an *element* of that, but if that’s your main takeaway on most occasions, I fear for what you’re missing.

    On the whole, I hope you realize that when you live the privilege of as much power as you hold, it’s almost *inevitable* that you’ll be missing several elements of what it is like to live on the other side of that power split. I hope you’ll hold that in mind and consider it deeply as you move forward.


  11. How about training the therapists how to do cognitive therapy for suicidal thoughts? As soon as I would bring up that topic, it’s like they lose all their counseling skills! Suicidal people are always told to get professional help, but the professionals are so unhelpful when it comes to suicide, it’s like they are completely untrained.

    • I did a training on suicide intervention with mental health therapists many years ago, when I worked at a volunteer crisis line. Our volunteer crisis counselors knew 10 times what the professionals knew about helping suicidal clients. Our emphasis was listening and understanding, focusing on what can be controlled vs. what could not, building relationships, and inviting further contact as frequently as needed. Most of the professional therapists didn’t seem to even have an idea what to do besides calling 911. They didn’t even have the skill to figure out who was contemplating doing something immediately vs. those who were feeling despairing but mostly needed to talk and connect. They were effectively clueless. That was in 1992. Things are far, far worse today, because at least the ones we were training knew they didn’t know, whereas now they can just diagnose them and send them to the psychiatrist or the hospital as soon as anyone even talks about the word “suicide.” Many therapists are simply scared by any suicidal statements and go with the safest approach for THEM, rather than the best approach for the client. Of course, there are many exceptions, but I’d say a majority of therapists are not really prepared to deal with a suicidal client, both in terms of training and in terms of their own emotional reactions. In fact, many therapists appeared to hospitalize people for much less serious things like self-harming in ways that are neither intended to nor capable of killing or even seriously hurting themselves. Which meant the self-harming people couldn’t even talk to their therapists about their urges without risking being hospitalized, so they called the crisis line to stay anonymous and to actually find someone who would listen.

      So you’re not wrong. A lot of therapists don’t actually have any training in helping suicidal people, and as often as not, it is not really safe to tell them if you want to just talk without being hospitalized.

      — Steve

      • Steve, I thought we had a therapist on the website awhile ago who stated that if she didn’t protect herself by hospitalizing the person involuntarily and the person went thru with the suicide, then she could be held legally liable. If I’m correct in my memory, then we’ve put thoughtful therapists in a double bind where their own self preservation trumps that of the person in need…

        • Absolutely true. Unless you have the courage of your convictions and the skill to know how to help, the safe play is to hospitalize even if it’s totally uncalled for and totally destructive to any chance of further therapy. It’s no wonder that clients don’t tell their therapists when they are suicidal, but when they don’t, they’re then called “manipulative” and get labeled “Borderline Personality Disorder.” If you wanted to create a system to discourage healing, the current one would certainly do the job.