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

Kurt Michael
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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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77 COMMENTS

  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.
    Sam

  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!

        • Steve,

          As someone who is twenty years old and has struggled with self-harm and suicidal ideation, and has additionally supported a number of friends with these same issues, I must say that you’re simply not understanding what makes this show so egregious. In a word: this show glorifies and encourages suicide. While it is true that teenagers are often faced with apathetic adults in reality, the show’s depiction of this issue only serves to reinforce the idea that troubled teens have no recourse available to them. It discourages the search for help, instead choosing to depict the cutting of a young girl’s wrists as the only way for her to achieve justice for what she has suffered. This itself is a massive issue: if the creators of 13RW truly cared about suicidality in teens they would have NEVER shown such a graphic ordeal. For many young people with self-injurous tendencies, depictions such as these are a sure-fire way to prompt an episode of self-harm. No, what the creators of 13RW truly care about is MONEY, and many people my age find this to be painfully obvious. They are playing into the insecurities of young people and affirming that no one could possibly understand them. Neurotypical teenagers may watch this show and be gripped by the injustices faced by the leading character; they may share posts on facebook pleading their peers to refrain from bullying, or fancy themselves a savior for deciding to talk to that weird kid who always sits alone at lunch. This show demonstrates a complete failure to address the root cause of suicide, which is MENTAL ILLNESS. Unfortunately, the tooth-and-nail struggle with mental illness is much less glamorous than dramatic re-tellings of rape and vindictive manipulations, so the creators of 13RW naturally chose the path that would lead to the most profit instead.

          I must say that I resent your remarks on involuntary hospitalization. My previous roommate attempted suicide whilst in the throes of an argument with me. She was emotionally abusive and delusional; accusing me of manipulations that I had not committed. The language she used with me was vicious and when I opted to defend myself, she began making suicidal remarks. After sending a friend to check on her (I was not in the building), I discovered that she had overdosed on one of her medications, Seroquel, and an ambulance was called. I will never forget the image of elevator doors opening to reveal my roommate being carted out of our room on a stretcher. The paramedics, of course, were not disposed to tell me whether she was going to live or die. She survived. The abuse continued, and I no longer speak with her.

          So, what would you have had me do? Submit to verbal abuse and threats of interpersonal violence in the interest of preserving her well-being? Am I responsible for her life? If she would have died, would it have been my fault? And if the overdose could not have been avoided, ought I not have sent someone to check on her and call for medical assistance? Was her hospitalization somehow more “traumatizing” than the impact of her death would have been? She was extremely mentally ill, suffering from BPD, PTSD, depression and anxiety, and some psychotic symptoms. 13RW is a mockery of my experience and the experience of so many struggling with mental illness. I cannot convey how absolutely dense it is of some commenters to insist that it “is that simple.” Suicide is a tragedy brought about by disordered thoughts and feelings. It is not the ultimate recourse in a society of evil teenagers who are hell-bent on destroying each other.

          You and many other commenters simply lack the phenomenological authority to be championing this show as a good thing for suicidal youth. It is not. It does not encourage teenagers to seek help. It does not encourage better clinical practices or less insidious procedures regarding involuntary hospitalization (which I do agree, of course, are a real problem). It encourages suicide and self-harm. It encourages martyrdom. To attack Dr. Michael for failing to recognize the “real” issues addressed by the show and suggest that he is misguided in his preoccupation with the practical side of suicide intervention is incredibly naïve.

          • I find your post confusing, as you seem to accuse me of things that I didn’t say. Of course, the suicide scene is overdone, and of course, they’re trying to make money. Obviously. I never said otherwise.

            You clearly have your own view of “mental illness” being the cause of Hannah’s suicide. I find that view somewhat bizarre in the face of all the crap that happened to her. Do you really think that people aren’t driven over the edge by bullying, by lack of support, by rape or sexual assault? What is the meaning of “mental illness” in this context? Are you implying that Hannah or a person like her would NOT kill herself despite all the abuse she tolerated if she were not “mentally ill?” Is there a proper, “normal” way to respond to being raped by a peer and then having to face him in school the next day?

            If you have specific responses or comments you are upset with, please let me know what they are before you go off on me. It’s impossible to really understand what you’re saying. However, I want to be clear that I NEVER said that this was ‘a good show for suicidal people to watch.’ I said that it depicts the dilemmas that kids face from the kids’ point of view, and that is why I found it valuable.

            I will end with the observation that I’ve talked to many, many suicidal people over decades, and not one has ever said they became suicidal because they watched a show or read a book or watched a movie. They all had difficult life circumstances they were trying to navigate, and were struggling to find a way forward. The idea that a show would put something like this in someone’s mind is, again, naive. People don’t suddenly become suicidal just because they see a show. You of all people should know this, having been there yourself. I also have been there, and the things that put me there or kept me there were real things that happened to me, or that didn’t happen, or that I imagined or feared would happen, and while a show or a song might remind me of a certain dilemma or depressing event, there is no way that any show could possibly have affected my decision to kill or not kill myself. Maybe other people are different, but that’s my reality.

          • You’re missing my point. Hannah’s suicide had nothing to do with mental illness, and that’s the problem. Most suicides do not involve people who were in ideal mental health before a slew of unfortunate events ruined their lives. Most people who commit suicide have already been dealing with mental illness in some capacity or another, and their suicidal impulses are worsened with the occurrence of crises in their lives.
            I think you’re simply out of touch if you believe a television show or book is incapable of impacting someone’s decision to kill themselves. As a professional you should know that suicidal episodes have a sudden onset and the decision to commit suicide is typically made within half an hour of the original ideation. Of course, the show will not transform someone who wasn’t previously suicidal into someone who is. But for the masses of teenagers out there who have already been struggling with this ideation, such a show could easily trigger a suicidal episode. When I used to experience suicidal ideation, I would read Kurt Cobain’s suicide letter as inspiration. Suicidal people commonly look to the example of others when trying to formulate a plan or decide whether its “worth it” or not. And this show, without a doubt, suggests to teenagers that it is indeed worth it.
            If that’s the impact that the show has, I do not care whether or not it’s a good depiction of the issues faced by young people. If the show is going to capitalize off of them, it ought to be suited for them. It seems as if you’re suggesting that the show is still valuable because it allows older individuals insight into the dramatic opera of high school, regardless of how egregious its affects on that age group may be.

          • So you were SEEKING support for your decision from Kurt Cobain’s letters. People can seek and fund such validation if they want to find it.

            I also very much doubt that anyone watching the entire series could view that Hannah’s suicide was “worth it.” It was clearly an act of despair following many attempts to find a way forward with her life. The consequences for her mother, her father, her friends, and her school were obviously devastating. How does it seem “worth it?” Just because she lit some candles before slashing her wrists? It is clearly a TRAGEDY from start to finish. I’d suggest that seeing what her mom and her dad and Clay had to go through as a result of her decision would discourage anyone from considering suicide. The idea that “they’d be better off without me” is clearly and completely dashed by the production.

            You continue to suggest that someone has to be “mentally ill” before they’d consider suicide. What on earth can you mean by that? Many people (including me) have suicidal thoughts that stem from having difficult experiences that they have difficulty coping with, including rape or incest or child abuse or neglect or war or gang violence or any of a myriad of crappy things that life has to offer us sometimes. Unless you define “mentally ill” as “having a hard time coping with life”, you have no grounds to stand on here.

            I am assuming that you are one of those who believe that “chemical imbalances” are behind “mental illnesses,” and conclude that Hannah or someone like her could never consider taking her own life unless such an “imbalance” was present. If that is the case, it is understandable why we disagree. However, I would love to see any actual evidence you can present to support such a hypothesis. At this time, no “mental illness” can be defined by any physiological process or measurement, including depression. As such, saying someone “has a mental illness” has as much meaning as saying someone “feels like crap because s/he has been abused and mistreated all of his/her life.” The idea that a person has to be “mentally ill” in order to commit suicide is simply an opinion with no scientific backing, if only because “mentally ill” is a vague and subjective term that doesn’t allow any kind of scientific conclusions to be drawn.

            In other words, people kill themselves or feel like doing so for a million reasons. Saying they are “mentally ill” avoids looking at the individual’s experience and values and process of decision making, which is, of course, what the series is really all about.

            Last comment: how is it glorifying suicide when another kid shoots himself because he can’t deal with the reality of your actions? Was Alex’s suicide romanticized? Was it?

          • I think the key piece here, is “triggers.”

            I don’t believe in triggers, I believe that I can choose the response to the input – though I may find the input disturbing. I do find the trend of greater graphic violence (this seems to be pushed by streaming-based series) disturbing, my response is my choice.

            However, when people are in grave distress, a “trigger” is sometimes the thing that throws them over the cliff. It takes slowing down and learning to be able to turn that reaction into a response.

            The Powers That Be do not care if our young people are killing themselves, as long as they sell enough soda, chips, shoes and fast food (and pharmaceuticals) to support their bottom line.

            LoganCW, many people here at MIA have thrown out the DSM categories of “mental illness.” The diag-nonsense was designed to sell drugs, to legitimize the psychiatric profession and make it sound more scientific – offering codes for insurance purposes.

            Certainly, when someone like Hannah gets bullied, raped, traumatized, she maybe wasn’t thriving before that happened – but why she wasn’t thriving isn’t necessarily a disease or illness. It is, instead, a series of events and strategies to deal with those events. Our lives are filled with trauma, and we’re not given a manual for “how to survive and move on.”

            Some of us are better at that than others of us. That does not make us “ill” or “diseased,” just needing help, adjustment, and learning the ability to slow down and respond instead of reacting.

            Emotions never killed anyone. Reaction to those emotions has.

          • Look, Steve, everything I’m trying to say is going right over your head. Actually, I don’t subscribe to the “chemical imbalance” theory, but that doesn’t mean that “mental illness” is some useless term we can throw into the garbage. The DSM categories are nothing more than our best attempt to group certain symptoms together. They do not represent any preexisting “diseases” caused by unseen entities. But it’s foolhardy to suggest that what we call “mental illness” is simply difficulty dealing with society’s demands. Severely depressed people do not have to have anything particularly stressful in their lives to feel depressed. Schizophrenic people don’t require a special tipping point that throws them over the egde, and individuals with bipolar disorder cycle through their mood episodes whether or not their lives are “good.” When I say mental illness I mean nothing more than symptoms that present in a psychological manner and have no clear somatic cause. People are impaired by these things, whether they’re chemical imbalances or not; whether they’re metaphysically pre-determined “natural kinds” or not. As someone with existentialist leanings I believe that we get to decide what mental illness is. I believe that mental illness is suffering that we cannot understand by any other means. I believe that mental illness is that which impairs one from living their life. It may be temporary or it may be chronic. It may be brought about by traumatizing events or it may seem to be inherent. Either way, we must develop a treatment system.

            And YES, the suicides are glorified, you’re simply contradicting me on this point. I’ll repeat myself: you do not have the phenomenological authority to tell me how this show affects mentally ill youth. Alex’s suicide represents success on Hannah’s part. Suicidal teens don’t necessarily believe that the world would be better off without them. They believe that they would be better off without the world; they feel hopelessly misunderstood, and a suicide by dramatic means such as Hannah’s may be their final attempt to force others to understand the nature of their suffering. Again, that is the message this show endorses. No one will understand your suffering unless you kill yourself. The show may indeed appear as a tragedy to those who cannot envision themselves as the titular character. But for those who can, this show provides a blueprint. I have observed the effects of this show on my age group, both in my personal life and in online communities. It is not a positive one, and nothing besides a reversal of the sentiments I’ve observed could convince me otherwise.

            JanCarol,

            I appreciate your comment, though I don’t feel that I precisely agree with you about the nature of “triggers.” When I say something is triggering, I only mean that it summons strong emotions that we perhaps were successfully keeping at bay. There isn’t a direct causal link between the trigger and the suicidal action. But the correlation is certainly there; if someone is more likely to be overwhelmed by their hopeless feelings, they are more likely to descend into a suicidal episode. Again, though, I appreciate the nature of your reply and of course agree with you concerning your qualms with the DSM and our societal perceptions of mental illness.

          • Well, you start your comment off with an insult and then avoid almost every comment I made, and then simply declare that you are right, and that Alex’s brutal shooting of himself is “romanticized” or “glorified?” It is very hard to take you seriously when you approach conversations in this manner. I’m not simply contradicting you. I made very specific points, such as the clear and severe consequences of Hannah’s suicide for others she loved, and the completely cold and pointless and totally UNGLORIFIED nature of Alex’s act. And of course, you utterly avoid the rest of the show and focus only on two scenes, one of which you don’t even really discuss at all but simply claim to have been “glorified” through some mysterious psychological mechanism.

            Your comments about “mental illness” continue to be confusing and illogical to me. If “mental illnesses” are just “symptoms that present in a psychological manner and have no clear somatic cause,” then my statement is completely true – there is nothing to say about Hannah’s “mental illness” except that she hated her life and wanted to die. I’ve never asserted anywhere that people don’t feel depressed and have related ‘symptoms’ or don’t “meet the criteria” for these DSM “disorders.” Hannah would 100% meet the criteria for “Major Depressive Disorder.” So you can easily say she was “mentally ill” just by watching the show. What did you want from the producers? That she be “diagnosed” during the show? If being “mentally ill” is simply grouping together unexplained “symptoms,” how is that different from saying that a person, for whatever reason, is overwhelmed by the conditions of his/her life? Any fool knows that a person’s experience is a combination of their own view/perception of things and the experiences that they have in the world. So what’s it mean to say she was “mentally ill”? And why is that important?

            These two questions are what is bothering me about your post. There is no logical path from “Hannah’s suicide was romanticized” or “The show had a bad impact on me and people I know” to “Hannah should have been depicted as ‘mentally ill.'” It makes no sense at all. Hannah WAS depicted as “mentally ill” by your definition. So what should the producers/directors/writers have done differently that would have made it better in your view, other than not writing a show about teenage issues from the teenage viewpoint?

            Oh, and just to be clear, you also completely dodged my comment that I did NOT recommend this show for people who are suicidal. I said that it showed teenage issues from a teenage viewpoint, and that’s what makes it valuable. Apparently, you don’t find that point worth responding to, even though it was the main point of my original comment, which made me wonder what your agenda really is here. Based on that observation, it did not appear to me to be your agenda to have a reasoned discussion. I’ll see how you respond to this one and draw the appropriate conclusion.

          • I wasn’t aware that accusing someone of not understanding your argument is a personal insult, but forgive me. I am aggravated because i do not seem to have the privilege of being taken seriously here.

            I’ll break this down line by line, since you refuse to do any sort of critical thinking regarding what the implications of my points might be.

            “I made very specific points, such as the clear and severe consequences of Hannah’s suicide for others she loved, and the completely cold and pointless and totally UNGLORIFIED nature of Alex’s act.”
            I did in fact address these “specific points” by way of the following remark: “Alex’s suicide represents success on Hannah’s part. Suicidal teens don’t necessarily believe that the world would be better off without them. They believe that they would be better off without the world; they feel hopelessly misunderstood, and a suicide by dramatic means such as Hannah’s may be their final attempt to force others to understand the nature of their suffering.” But I suppose I need to explain myself further. The “clear and severe consequences” of Hannah’s suicide are WHAT IS DESIRED BY SUICIDAL YOUTH. They want their deaths to be as impactful as possible. They want to inspire regret in those who have wronged them, just as Hannah very successfully inspired regret in Alex. They want to convey the sentiment that they HAD to do this, because the people in their lives left them no further options. The suicides aren’t “glorified by some mysterious psychological mechanism,” they’re glorified because the pretense under which they are committed falls perfectly in line with the massive anti-recovery movement that can be found amongst people my age online. It is becoming increasingly common for mentally ill youth, especially those with personality disorders such as borderline, to respond to the suggestion of treatment as if it were an insult. They are suffering, and the world ought to feel the weight of their despair. What better way to lash out at an unaccepting society than to put your blood on their hands.

            Next. “Hannah would 100% meet the criteria for ‘Major Depressive Disorder.’ So you can easily say she was ‘mentally ill’ just by watching the show. What did you want from the producers? That she be ‘diagnosed’ during the show?” What I would have liked from the producers would be some portrayal of the symptoms, by which I mean the disordered thought processes that preclude a suicidal episode, rather than the revenge porn we’re provided with. Even the show markets itself by prompting the audience to keep watching to find out “who killed Hannah Baker.” Hannah Baker killed Hannah Baker, and she presumably did it in the midst of a whirlwind of conflicting thoughts and feelings. The audience does not get any insight to the sort of mental life that precedes a suicide. They are merely shown an act of direct retaliation.
            Following this remark you ask, “If being ‘mentally ill’ is simply grouping together unexplained ‘symptoms,’ how is that different from saying that a person, for whatever reason, is overwhelmed by the conditions of his/her life?” What? Are you trying to tell me that the obsessions and compulsions suffered by individuals with OCD are merely “conditions of their lives?” You sound like you are denying the very existence of neurodiversity and are rather trying to pin all psychological symptoms on some inherently evil society. We can observe very clear examples of symptoms that are purely circumstantial, symptoms that are purely endogenous, and several that fall somewhere in between. It is not nature vs nurture but nature AND nurture that result in the development of mental illness. Additionally, “without a somatic cause” and “unexplained” are not the same thing. I don’t know about you, but I’m not a determinist who subscribes to the notion that we lack free will because all of our actions are predetermined by chemical reactions in the brain. Mental events have causal effects as well, and mental events are not somatic. Just because we can’t explain mental illness in terms of bodily deviance doesn’t mean that we can’t try to explain it at all.

            I’ve ignored your protests about saying this show is ideal content for suicidal youth because I haven’t actually accused you of saying that in the first place. My original comment was this: “You and many other commenters simply lack the phenomenological authority to be championing this show as a good thing for suicidal youth. It is not. It does not encourage teenagers to seek help. It does not encourage better clinical practices or less insidious procedures regarding involuntary hospitalization (which I do agree, of course, are a real problem).” By “a good thing for suicidal youth,” I mean something that will impact SOCIETY in a way that will improve conditions for suicidal people, like I tried to emphasize with my point about failing to provide any portrayal of suicide prevention tactics or addressing the practical realities of the act. Furthermore, even if that WERE what I was originally trying to say, the fact that you deny your recommendation of the show to troubled teenagers while simultaneously lauding the show as “valuable” is deeply misguided. As I’ve already said: “It seems as if you’re suggesting that the show is still valuable because it allows older individuals insight into the dramatic opera of high school, regardless of how egregious its affects on that age group may be.” If a show about suicidal youth has a negative impact on suicidal youth, I simply don’t care how touching other demographics may find it. The suicidal individuals are the ones whose well being ought to be prioritized, and as I’ll remind you, the only thing that could possibly abolish my negative judgement is a sudden reversal of the testimonies from suicidal youth that condemn this show as callous and unrealistic.

          • OK. So you didn’t accuse me of saying this was good for suicidal youth, but I was “championing this show as a good thing for suicidal youth.” You are either unable to articulate your point or are contradicting yourself.

            And saying I probably won’t be able to understand you isn’t insulting? Is your intellect so superior that even a bright person won’t be able to understand your subtle prose?

            You clearly have your well-molded and impermeable viewpoint in place and are unable/unwilling to see anything different. It is not worth my time to try and explain to you how honest the portrayal of adults being unwilling or unable to meet kids where they’re at due to their own authoritarian or self-absorbed attitudes, nor the repeated references to Hannah’s missed opportunities to reach out for help, nor the honest treatment of bullying that is almost never seen in film or television, nor the direct confrontation of rape culture, nor the message to peers and adults that they ought to ask more questions and offer support to kids who are suffering has ANYTHING whatsoever to do with reducing suicide.

            I’ll end by observing that your insistence that they show the “real symptoms” of “major depressive disorder seems ridiculous. The reason this was the most popular Netflix original ever is not because people want to watch someone commit suicide. People watched because it felt REAL to them. Again, I’ve worked with tons of suicidal people and have been so myself. You are one person with a few contacts with similar experiences. Your claims to superior moral authority are utterly baseless, as I believe anyone reading these posts can see. I think the proof is in the pudding – kids and young adults LOVED this show. It’s not perfect, but it has great value for kids who deal with these issues and never hear them talked about, IMHO. You’re free to disagree with me.

            Suicide is a complex decision. Your generalizations are unsupported by anything but your own experience, as for the most part are mine. People are entitled to their own opinions, but assuming such a superior attitude doesn’t encourage discussion. If you opened your mind, you might find that not everyone who is suicidal or depressed is alike, or sometimes even remotely similar. It is this tendency to try and put everyone who is suicidal (or whatever) in the same “basket” that makes the “mental health” system as screwed up as you claim to believe it is. If you want it to change, you’d best start by dropping your assumption that you already know everything and can lecture people you don’t even know from your very limited personal experience.

            But in any case, PLEASE quit attributing things to me that you have no reason to know or pretend to. Speak from your OWN experience and stop generalizing about people you don’t know, including suicidal people you’ve never met. Real healing starts with respect, and you will be a lot more helpful to others if you start by respecting them and listening when they tell you that you’re behaving in an insulting manner, instead of defending your own “rightness.”

          • LoganCW:
            “. It is becoming increasingly common for mentally ill youth, especially those with personality disorders such as borderline, to respond to the suggestion of treatment as if it were an insult”

            Here’s the thing – “treatment” by psychiatry is ***more*** likely to induce suicide, so these “disordered” youths would be better off without it.

            The drugs induce numbing and akathisia, which, in combination put people of all ages at risk for suicide and other desperate acts.

            “Treating” also includes labelling (which you do so readily) and that has stigma and trauma associated with it, too.

            Further, since you are fond of the DSM, there is no “treatment” for “borderline” and many of the people I know diagnosed with “Borderline” have been rejected by hospitals and doctors for that very reason.

            Steve writes: “The reason this was the most popular Netflix original ever is not because people want to watch someone commit suicide. People watched because it felt REAL to them”

            This bothers me. The trend since “streaming” channels with exclusive programming is not regulated by FTC or otherwise. And I’ve noticed that the violence is about 5x greater than normal, about 2x what I might find in a R rated movie.

            The movies cannot show sexy stuff, but they sure do show the violence, and it seems to me like a trend towards “snuff films.” Everybody strives to catch that moment of snuff. Ask the Coen brothers how many different ways you can portray death (and they are particularly artful about it – not all are, and it is proliferating). It’s not gladiators in the arena, but it’s darned close, and it seems to me that this series hyped a self-snuff (even though it was acting, not real) to attract audience!

            That bothers me.

      • 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.

    Richard

  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. Steve, I can say with confidence that the training programs in Psychology with which I have been associated are not beholden to the medical model or biological psychiatry, nor are any of my students. You used a single anecdote from one exchange to argue how there is a complete disconnect between providers and consumers. I certainly acknowledge how big pharma and the medical establishment has had undue influence over mental health and psychology in particular for decades. In fact, I require that all of my students read Brett Deacon’s (2013) article: The biomedical model of mental disorder: A critical analysis of its validity, utility, and effects on psychotherapy research. It appeared in Clinical Psychology Review. It provides an excellent summary of the failure of the medical model. My students are bright, critical thinkers, capable of sifting through the literature in search of effective ways of helping others. Moreover, they are not satisfied with overly simplified (and wrong) assumptions about the nature and treatment of mental health impairments. They are committed to addressing the multifactorial issues that come up in day to day practice, including the why and how associated with suicide prevention. As for me, I am committed to science and practice of effective psychotherapy and yes, I favor third wave interventions (CBT, DBT, ACT), but that does not suggest a blind loyalty to these approaches. Indeed, as we saw in the Treatment of Adolescent Depression Study (TADS), CBT was not that effective. Consequently, we learned that some of the modular aspects of this particular CBT program were weak or implemented poorly. These “lessons” from the literature are then taken into account when serving clients. So, the commitment here is not a robotic allegiance to a particular paradigm, but to providing compassionate, effective clinical care for the individuals and families we serve.

    • I am quite sure that YOUR students are trained in a different way, Kurt, but I’m pretty confident that many if not most in the USA are trained in DSM diagnosis and brain-disease theory, even if some rebel psychologists/therapists provide different perspectives. And just like the kids at Hannah’s high school, whatever their prior training and beliefs, they have to deal with the oppressive system that they will be operating in, and that system challenges anyone who wants to look at “mental illness” in more human terms. I say this as a mental health professional who got out of the field and into advocacy after I could no longer stand seeing what happened to my clients who were hospitalized or even “treated” by the agency I worked for. I have many more than one anecdote to share (though it was actually a study, not a single anecdote), and the comments I make apply not only to the mental health system, but to almost any institution in US society today. That’s the point I was making – that Hannah’s difficulties were not a result of a “mental health issue,” but of her and her friends/associates having to survive in an oppressive environment day to day and the absence of anybody in a position of power willing to or capable of intervening. Perhaps I have put this in better terms this time and you can comment on this aspect of suicide prevention, which I believe is the main point the series is trying to highlight, namely, that someone has to acknowledge and challenge the power dynamics in the school and the larger environment for this kind of depressing hopelessness really to be challenged.

      — Steve

      • Okay Steve, I definitely agree that power dynamics are always a relevant consideration, whether we are talking about parents and children, school administrators and students, or clinicians and patients. One of the most gut wrenching aspects of 13RW were the rape scenes. I just had an email exchange with one of my colleagues who correctly pointed out that for those who have been subjected to ACEs, their risk of suicide increases cumulatively, with each additional ACE. For instance, my colleague reminded me that for a child or adolescent with an ACE score of 7, their risk of suicide is 51 times greater compared to youth with a zero on ACEs. The scene where the counselor turns the tables on Hannah and essentially blames her for the trauma is abhorrent and a sharp reminder of exactly what NOT to do as a clinician. It is a cautionary tale that should remind us all about the horrific impact of trauma, up to and including suicide. Honestly, those scenes and issues were the real story behind 13RW in my opinion. But, I do not think that the scene was representative of what most counselors would do in that instance. I have spent my career surrounded by caring and effective professionals who are advocates first, the second priority of which is to expedite referrals for effective clinical care for their legitimate ailments, especially those who have been subjected to the injustice of trauma. I fear that scenes like that might create a chilling effect on help seeking of any kind, something that I believe would be harmful.

        • Fair enough. The ACE study has brought an increased awareness if the impact of trauma, though my experience is that the mental health system has been very slow to respond. Perhaps you are fortunate enough to travel in more enlightened circles than those I have worked in.

          However, years of advocating for foster kids has shown me that very often, we as adults really do care and BELIEVE what we are doing is right and helpful, and yet those receiving our services don’t feel that way at all. I suppose the lesson I find is that kids have a lot to say but the adults don’t often create safe spaces to listen. I just had occasion to talk to a young couple in their early 20s last night who had seen the whole series (I’m only about halfway through, and most definitely NOT looking forward to the suicide scene, it sounds AWFUL!) and both of them said that the conditions represented in the school in the series were not an exaggeration and seemed very familiar to them. I think it’s way too easy for those with power to imagine we are doing good without bothering to consult those we are purporting to help, and I hope that is the real takeaway from this provocative series.

          • I think you stated this in passing, Steve, but I think it ought to be restated more clearly and forcefully: trauma victims are VERY cautious about speaking with others about their trauma experiences. We must EARN the right for others to share with us. And usually it’s a process where the victim starts small and as trust is earned, the victim may choose to share more. Sadly too many experts and people in positions of authority act like they ‘deserve’ to be told ‘the whole truth immediately’ just because they asked.

            It took me 7 years of patience, kindness, and unconditional love before the last girl in my wife’s system felt safe enough to come out and begin to connect with me and 2 years later she still doesn’t tell me everything. I gently prod for more but I NEVER push. I NEVER assume the right to her secrets and trauma, and yet so often I see and read things by experts who just kind of have an attitude of outright disbelief, victim blaming or ‘well I asked and she/he didn’t say anything.’ That’s just not how one works with a severe trauma victim.

            I approach my wife from a completely egalitarian plane when I am helping the various girls deal with their trauma because anytime I move toward force and authority, the girls move away or will divert and ‘give me what I want’ but not necessarily the truth…

          • Based on your comment here, I’m sure you would be intrigued by the Youth Voice Project that is geared to address the very problems and injustices you highlighted. As adults, we regularly fail to consider the perspectives of youth, which truly imperils effective clinical practice. As just one example, we might get full informed consent to treat youth under the age of 18 without fully honoring the child’s need and right to provide informed assent. In fact, though children have less legal standing, we need to go the extra mile to ensure that their assent in respected and honored and that their viewpoints are seen as primary as we go about the task of providing care. This is true in research as well and must be addressed clearly as part of any approved empirical protocol.

          • Sam, your comments are incisive and effective as always – thanks!

            Kurt, I would very much be interested in hearing more about that project – do you have a link? It’s easy to give lip service to “informed consent,” but how many clinicians really do that even for adults, let alone kids? In my experience, not only do foster youth not get informed, they are outright lied to about what is being “treated” and what their options are, let alone the common fear of telling them about medication side effects. It sounds like this program would directly address that issue, and I’d love to hear more about it.

            Personally, I think we should do a lot more than “consider the perspective” of the youth we’re treating. Their perspective should be the main jumping off point of any planned treatment, and should constantly be consulted as our guide to whether or not we are being effective in our work.

            Thanks for your response!

            —- Steve

          • http://www.youthvoiceproject.com/

            We have used this approach in spirit, in many of our programs. Montana happens to be one example where the approach is used often, notably on American Indian Reservations. Consult the work of Stephanie Ironshooter, Erin Butts, and Don Wetzel Jr. All 3 work for the Office of Public Instruction (OPI).

        • I’ve got people close to me who have struggled with Self Injury, which also manifests as suicidality in its extreme forms.

          One of the most beneficial programs for this was S.A.F.E. founded by Wendy Lader (now run by her co-founder): Self Abuse Finally Ends.

          One of the most valuable principles of S.A.F.E. was a complete ban on graphic language, images, as “triggers.” While I don’t like the idea that something “triggers” someone else (we choose how we respond) – the ban on graphic descriptions of self harm were very valuable.

          I would think that, in the case of ACE and trauma, the graphic depictions of rape could be quite traumatic, as well. I know when my trauma is addressed – sometimes quite innocently – in media – I find it too much to bear.

          On the graphic depictions of rape and suicide, and your objections to them in this series – I concur. In general I find that modern media is too edgy, in order to keep the attention of our youth. This is an extreme example of it.

          But – could it raise the issue – without the violent “hooks”? Would it get the attention and discussion that it is getting? It’s a razor’s edge.

    • I work in a state hospital where we have medical students and psych interns who rotate through one of the units. These people come from the university medical center in the city. I would have to say that in my dealings with these students and interns that your students are the exception. What Steve describes is the reality with most of the people who come from that medical center. They are totally immersed in the Bio-Bio-bio business and have fallen completely for the lies put out by the drug companies and psychiatry that people have chemical imbalances in their brains. Many of our “patients” can lecture the students in the gaping holes of their education pertaining to so-called “mental illness”. Most of them are also terribly afraid of us and go around the halls in huddled groups with their arms clamped about their upper bodies and constantly looking from side to side as if they’re going to be attacked at any moment.

      • Stephen, I do feel fortunate to be surrounded by open minded, smart, and compassionate learners. Their core values include a sense of duty to advocate for their clients first and foremost and to value a client’s right to self-determination. Yet, I am also familiar with the circumstances you described, having spent a great deal of my early career in state institutions and hospitals. Those experiences led me to make a major change in my career direction, the one I am in currently. I recall several formative experiences while working hospitals and correctional units that were awakenings for me. One time, when I was working as a Psych Tech, the Unit Manager called a meeting of the Techs and coached us on how to write our notes in a manner that would satisfy the care managers from insurance companies to authorize more bed days. It was sickening. Another time, when working at a correctional unit, the superintendent said the “inmates did not deserve any treatment and should be locked up for the rest of their lives.” He was referring to 14 and 15 year old boys. It was at that moment that I knew I had to get out or risk becoming institutionalized myself.

  8. 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.

      Richard

      • Thank you Richard. I am about halfway through the piece and I certainly see merit in many of your arguments. I have been a direct witness to some of the injustices you highlight, especially earlier in my career. However, in the rural communities in which I have lived and worked for the last 25 years, the most common occurrence is a virtual dearth of providers or hospitals. There are also major problems with access due to other barriers (transportation, lack of qualified providers, no insurance, skepticism of professional healthcare, geographic distance). So, as least in my experience, we have several forces working against us in our attempts to bring effective clinical care to the children and families who live in remote areas. However, we are a persistent bunch and remain committed to serving individuals who would otherwise not be seen at all.

  9. 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.

  10. 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.

  11. 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.

    Sera

    • Sera, thank you for reading the article. I certainly don’t vouch for all of the prevention programs that are part of a national data base, nor did I mean to imply I vetted them fully, only that it is a source of information for individuals who wish to examine their utility for particular community needs. With respect to the means restriction literature, it is a well-established public health approach to preventing death by suicide. I acknowledge that it is not a “one size fits all” approach, but again, depending on the needs of a particular culture or community, it has been shown to be an effective adjunctive intervention as part of comprehensive suicide prevention efforts. For example, as part of the CAMS model, lethal means restriction is but one aspect of stabilization (safety) planning. Means restriction was never meant to be a “stand alone” intervention. I urge you to look deeper into the lethal means restriction paradigm, given that your comments suggest you might have a somewhat limited appreciation of the approach.

      Regarding your last points, beginning with “people basically being happy to be locked up and become powerless,” I honestly have no idea what you are referring to here. I made no such comment or claim, either in my article or in my follow-up comments. On the contrary, I emphasized how I fully advocate for a client’s right to self-determination, not only for those who can provide legal consent, but notably for children and adolescents who only have the right to assent to treatment. As for your remark about my “privilege” and “power”, I fully admit that as a Caucasian male I do, in fact, have power and privilege, but I have committed my life’s work to using it in a manner that uplifts and honors others to the best of my ability. I certainly have my failings both as a human and as a professional, but I have never taken power or privilege lightly.

      • Okay. I was trying to be reasonably polite. This might be somewhat less so.

        Your response – and much of your blog – comes across as pretty pretentious and … well, I’ll leave it at that.

        In fairness to you, I did mix up some of my notes and was attributing some of what Dickson said above to you…So, apologies for that much.

        However, the rest is for you. Your overly academic way of speaking, assumptions about what people (including myself) do and don’t know, and globalized way of speaking about *all* of your students and virtually *all* of your co-workers as somehow different and more special than almost every other clinical worker in the country is extremely off putting.

        And sure, you can’t vouch for an entire website of tools… The problem is, if you’re going to blindly direct people to such a thing, you might want to offer *some* information about just how much drek they might have to sort through. It’s not just that some will work better culturally for some groups than others, and vice versa. Some of it is actually dangerous. Some of it is primarily a marketing tool to get kids into ‘treatment’.

        It’s interesting that you defaulted to your whiteness and maleness when referencing my comment about privilege. It is true, you are privileged in that way, and I share the privilege of whiteness with you. However, what I was specifically referring to is your privilege of power in your role. You’ve never been – at least as far as I can tell – on the opposite end of the ‘suicide prevention’ stick. I have. Almost everyone I work with has. The privilege of not having ever been there – and not living on that cusp now – is big, and I do not think that you recognize it.

        You’re all theory and acronyms. I’m familiar with CAMS (and if I wasn’t, I luckily say through the aforementioned extraordinarily painful and offensive suicide training on Tuesday where it was reviewed). I’m also familiar with the BS that is ‘Zero Suicide’, I’m intensively trained in DBT by Charlie Swenson and Cindy Sanderson. Blah blah blah. I *know* what you’re talking about.

        And I disagree with most of it.

        • You make some pretty hefty assumptions about me and my background. You have no clue about who I am yet you make several claims about how I don’t know the other side of equation. How can you possibly know this? I am fine with you disagreeing with the points I raised, but I have no earthy idea why you have to resort to personal insults, especially when you began your response by admitting that you incorrectly attributed some of the comments to me that were offered by others. By the way, I was not referring to zero suicide or DBT. I was suggesting you look into the Means Matter program first developed by a woman named Cathy Barber and her colleague, Elaine Frank, who is credited with developing the CALM program.

          • Yes, I misapplied *one* statement (about people being ultimately happy to be in hospital). Everything else has been a response to you. Nothing I said in my last comment – and only one bit of my first comment – had anything to do with what I misapplied.

            Kurt, You’ve come here to this site for the first time… a site full of people who’ve lived these things (though that’s certainly not representative of all bloggers here or the site’s full point), but you don’t seem to have a lot of respect for that. Or, at least, that’s how you come across to me.

            No, I don’t know who you are. But, I do know that what you’re conveying – as I believe someone else said – comes across as feeling tone deaf to me. You’re talking about what you believe to work in the world of ‘suicide prevention’ (a problematic concept at its very roots), but you are speaking in some of the least human-sounding language about what is the most human of matters: life and death.

            I don’t think you can fully see it, which is why I brought up privilege. I hope something makes it all more visible to you at some point.

            Sera

          • I really do get both sides if this conversation, and I understand why it is uncomfortable for you, Kurt, and I also understand your frustration, Sera.

            I don’t think Sera is trying to be hurtful but is speaking from the heart as a person who has experienced the “help” of the mental health system and found it quite harmful. It appears you have embraced the science that Bob has published, which is great. But I think. Sera’s getting at what I was talking about earlier, and it goes deeper than Big Pharma corruption.

            Perhaps the clarity comes from your response to my comment when you said that “power dynamics have to be considered.” I think a different viewpoint, which I am trying to convey, is that “dealing with power dynamics between provider and client is central to ANY effort at creating healing.” I believe that people who have been harmed by the system tend to take the second view. I think it is hard for a professional person who hasn’t been in that position to really understand why, and it often comes across as hostility, and actually can BECOME hostility if enough frustration builds up. But what Sera says is absolutely true – the privilege of being “the professional” allows us (and I include myself as a fellow professional) to dismiss or minimize the impact of our power differential, and this gets in the way of or sometimes completely prevents a healing relationship from forming.

            I don’t know why I have been granted the ability to bridge this gap, but somehow I really see and understand deeply the cost of resting comfortably in our “professionalness,” as well as the true power of stepping out of those shoes and meeting our clients where they are without the slightest judgment or condescension.

            It is hard to describe if you haven’t been there, but it really does come across in your presentation that you don’t quite grasp this reality, although I am quite sure you do excellent work within the context of your role and that clients would be VERY fortunate to see you vs. the average mental health professional. There is just a possibility that you might be able to take one step further to seeing the reality of your clients, and I am hoping this discussion might make you aware of that step. Again, I’m not saying you’re doing something WRONG or that you are a bad actor and I’m not minimizing the work you’re doing to make the mental health world more respectful of those it serves. But Sera’s viewpoint is (I believe, not trying to put words in your mouth, Sera, so please correct if I’m off) just the viewpoint I was wanting to point out – the idea that it is the CLIENT (if that’s even the right term) who has the right to define his/her experience and whose viewpoint and needs must be the touchpoint of any intervention.

            If you had been a recipient of these services yourself, I think you’d see a different perspective that comes from chronically being in that one-down power situation and having to be careful not to say the wrong thing because some “helpful professional” will decide what is “good for you” and make you have it whether you want it or not (and I don’t just mean drugs here). It’s like being a kid in school again, except the punishments for stepping out of line can actually imprison you, disable you for life or kill you.

            Not sure what else I can say. I know not everyone is always a diplomatic as they might be on this site (though in fairness, I thought Sera’s first message showed a strong effort in that direction), still, a similar message has been communicated a number of times by a number of different people, and maybe there’s something there you’re not hearing. That’s all I’m saying. If I didn’t think you had it in you, I wouldn’t have put this much energy into it. If it’s not something you can get your arms around, that’s OK with me, but I don’t think the message is intended to hurt, it’s intended to inform, whatever form it has taken. I think there’s something there for you to take a look at, and I believe you’re enough of a real professional to hear that message if you can sit with it for a bit.

            Hope that helps!

            —- Steve

          • Steve,

            Yes, I think you’re on track and are understanding what I’m getting at very well. I *would* ditch the world ‘client’ (as you seemed to realize during your post) as I’ve seen too many people internalize that they are ‘client’ into their identity and that *alone* can keep them stuck in a system that often isn’t truly helping them. But the rest of what you say is great.

            Kurt, I don’t think anyone here (myself included) are trying to say that you are ‘bad’, but I am saying that you haven’t hit the mark yet… You and co-workers may be miles better than the average clinician who hasn’t considered some of the things you have… But you *and* your co-workers and students still seem to be missing a huge piece of the puzzle.

            If, as you indicate below and Steve says above, you’re only here because you care about Bob’s work and the problems with the pharma industry, you’re missing how deep some of the system’s problems run. I don’t mean the occasional time when it got so big that you were able to see it again (as you’ve named a few exceptional examples above), but when it just stayed at that sort of day-to-day level of bad and power-ridden and oppressive so that it was mostly invisible to those who weren’t looking for it.

            This is the nature of most systemic oppression. The big and obvious examples are able to seen by *most*. But the system actually runs on the more insidious, harder to see stuff… Harder to see because you’re on the power end of it, and so it just looks like business as usual to you. And by you, I don’t mean *you*, but really anyone who is living on the privilege end of the stick (so, also you).

            It’s the *same* phenomenon that means the average white person *can* easily see the really egregious examples of racism, but has a much harder time pulling out the conditions or microagressions that are truly what sets up the environment for those bigger things to happen… Same with sexism… and homophobia… and all of it.

            I hope you’ll spend some more time trying to see.

            -Sera

          • Wow, I just realized how appropriate the title of this article is! This really is a clash of perspectives, but not necessarily the perspectives outlined in the article. I think the real clash of perspectives is between the more powerful (professionals) and the less powerful (let’s just call them “recipients” for now) who meet in the crazy world of “mental health.” Maybe it’s easiest to understand if looked at that way – as a clash of worlds. The problem being that when worlds clash, the more powerful are able to continue to maintain that their world is the “right one.” Similar comments apply to the recent intense discussion of “reality” vs. “delusions.” Hence, my comments that power dynamics are the most important aspect of a helping relationship, and if they are not resolved, it’s hard to get beyond a fairly rudimentary level of “helping.” At least that’s my experience.

  12. My interest is writing for Mad in America is based primarily on my immense respect for the work of Bob Whitaker. I have read his work for years and believe that he has called attention to injustices perpetrated by the pharmaceutical industry that has no interest in policing itself. So, he has been an unwelcome whistle blower to many. But to countless others, he has been an amazing advocate.

    • My dealings with forced treatment might help you understand the unjust use of forced treatment occurring in our society today. I was force hospitalized twice, the first time I was literally dragged out of the comfort of my own bed by five paramedics while the sixth paramedic told the other five that what they were doing was illegal because I was neither a danger to myself nor anyone else. Although, there were doctors who were paranoid of a non-existent but legitimate malpractice suit, and pastors and bishops who enjoyed profiteering off of covering up the abuse of my child, who did consider me a threat.

      I was shipped a long distance to a now FBI convicted ELCA hospital doctor, who was eventually convicted for having lots and lots of patients medically unnecessarily shipped long distances to himself, “snowing” the patients, then performing unneeded tracheotomies on the patients for profit. I was “snowed” with massive quantities of drugs known to make a person “psychotic,” via anticholinergic toxidrome poisoning. But thankfully I avoided the unneeded tracheotomy and my insurance company refused the “snowing” psychiatrist’s demand to pay for me to be hospitalized for life.

      The second time I was force hospitalized was because I was lying in a park on a beautiful morning, minding my own business, looking at the clouds, albeit somewhat in shock after just finding the medical proof that the neuroleptic drugs can create “psychosis” via anticholinergic toxidrome, since all the psychiatrists and mainstream doctors deny this reality.

      I was taken to a hospital by a policeman, given a physical which resulted in a “medically clear” diagnosis. But I was not released, and instead shipped in the middle of the night, medically unnecessarily, a long distance to the same psychiatrist who “snowed” me at the ELCA hospital. I told the idiot psychiatrists at that place that I was allergic to their drugs, and that it was against my religion to be forced to take them. But they held me down and injected me with a neuroleptic anyway, at which point I asked if anyone spoke English, and started beating on my chest because I was allergic to the neuroleptics and did not want to be made “psychotic” via anticholinergic toxidrome again. Thankfully, my psychiatric stigmatization was downgraded to an adjustment disorder stigmatization and I escaped the insanity of today’s gaslighting “mental health” industry.

      Forced psychiatric treatment should be abolished since it’s being used to cover up child abuse en mass, as well as proactively preventing legitimate malpractice suits. My PCP who committed the prior malpractice did end up killing a subsequent patient due to an ankle problem later, which may have been prevented if psychogists and psychiatrists had not gaslighted me to cover up the malpractice and medical evidence of the abuse of my child in the first place. And God knows how many more children were raped due to psychologists and psychiatrists aiding and abetting the molestor of my child.

  13. To Steve, Sera and others who have commented. First, thank you for weighing in! I admit to being a complete novice at writing for this kind of venue. I had no idea what to expect and it has been a learning experience. The MiA community is clearly a tight-knit and committed group, something that I admire. I also know I have many blind spots. But, I would add that many commenters have made, in some cases, sweeping generalizations about my background that are far from the truth. No essay can be comprehensive enough to cover all of the bases or perspectives. I will certainly endeavor to think long and hard about the points made during this extended discussion and I sincerely hope others will extend to me the same courtesy.

    • Can’t ask for more than that. Sorry your first go was a little rougher than expected! I appreciate you hanging in through a difficult conversation, and I hope we’ll be hearing more from you in the future. I think in the end it was a very important conversation about topics that are central to this project of “rethinking psychiatry,” and while I wish we all could figure a way to have these discussions with less rancor, it’s a very emotional subject, especially for those who have been “helped” in some not very helpful ways by the system.

      Keep the faith!

      — Steve

  14. 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.

  15. Dickson (probably long gone but I feel worth a reply)

    “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.”

    Pharmacogenetics it is very specific, has been around along time, and all the inhibitors/blockers of cytochrome P450, they include valerian found Nytol and other sleep aids even black tea inhibits all of cyctochrome P450.

    http://www.todaysdietitian.com/newarchives/121610p26.shtml

    “Plenty of research suggests that drinking tea is healthful, but research also shows that black tea can have powerful inhibitory effects on the P450 drug-metabolizing system. In a laboratory study performed by Canadian researchers, black tea was found to be a more powerful inhibitor of the enzymes than single-ingredient herbal teas such as St. John’s wort, goldenseal, feverfew, or cat’s claw.5 Herbal tea blends were second only to black tea in their inhibitory effects. While the researchers said it is difficult to extrapolate the findings and precisely apply them to humans, they do believe the study accurately identified products for low or high levels of drug interactions.”

    Note the date on this BBC artical on pharmacogenetics 8 April 2000:

    http://news.bbc.co.uk/1/hi/health/704577.stm

    “One day it may be considered unethical not to carry out such tests routinely to avoid exposing individuals to doses of drugs that could be ineffective or even harmful to them.”

    Young people do not a well formed CYP450 system to boot.

    Do you do a cyctochrome P450 test on your teens before you subject them to these drugs to ascertain if they will go into akathisia ?