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.
- Centers for Disease Control and Prevention (2013). Mental health surveillance among children: United States, 2005-2011. Morbidity and Mortality Weekly Report, 2, 16-17. ↩
- 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/ ↩
- Centers for Disease Control and Prevention (2016). Youth risk behavior surveillance – United States, 2015. Morbidity and Mortality Weekly Report, 6, 10-13. ↩
- 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. ↩
- 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. ↩
- 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. ↩
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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