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Guidance For Clinicians

#13RWclinicians

Netflix released the third season of the controversial series 13 Reasons Why on Friday, August 23rd, 2019. The 13 Reasons Why Toolkit is non-Netflix affiliated and this section was developed by an international coalition of mental health experts with the intention to review the scientific literature as it pertains to all three seasons of the series, as well as to provide practical advice and resources to help medical professionals and mental health clinicians respond appropriately.

1

Provide guidance on viewing

  • Advise at-risk youth NOT to watch the series.

  • Caution against binge watching, as doing so with intense content, particularly in isolation, can be associated with increased mental health concerns.

  • Have collaborative discussions to discuss potential risks related to viewing graphic media portrayals of difficult content (e.g. suicide, sexual trauma, abortion, addiction, violence, traumatic grief), and if doing so, how to recognize and seek immediate help for negative reactions if they occur.

  • If youth do choose to watch the show, recommend they watch it with a parent and/or trusted adult and talk about their reactions.

  • Clinicians who work with youth may want to consider watching the series themselves in order to be better equipped to discuss the difficult content and gently correct misconceptions and distortions.

2

Guide thoughtful journalism

  • If you choose to make yourself available to media, have a clear and concise message that emphasizes the benefits of mental health care, destigmatizes mental illness, and is informative about available resources. See Suicide Prevention Messaging Guidelines for details.  

  • In order to mitigate risk, clinicians can help advocate for responsible reporting, by reminding our media partners of the recommendations for:  

3

Promote help-seeking behaviors

  • Throughout 13 Reasons Why, adults are often depicted as incapable of listening or understanding. Even though the series does later portray a few adults who are caring and available to listen, it rarely depicts youth reaching out to these individuals. It is critical that clinicians help youth understand that mental health professionals really do care and that treatment is effective and safe! Distressed adolescents tend to initially turn to peers for support, but it is important for them to recognize that family members, school staff (i.e.teachers, counselors, coaches, nurses) and primary care practitioners tend to have more information and resources to help youth access mental health services.

  • Clinicians can be leaders in their own communities through familiarizing themselves with helpful community resources (e.g. NAMI Helpline), educating peers and professionals, and engaging in advocacy efforts to destigmatize mental illness and promote help-seeking behaviors in youth.

What Clinicians Can Do In Response

PDFs are updated periodically to reflect the most current information on this page.

4

Support for youth at risk

  • Youth with histories of exposure to physical violence, traumatic loss, addiction, suicide or sexual assault may be triggered by direct or incidental exposure to sensitive content on screens. Even a youth who mindfully avoids watching the series may not be able to avoid traditional news coverage, social media discussions, or casual conversations about the sensitive content.  Clinicians can support their patients in the following ways:

    • Encourage youth to set boundaries and limits about what they will and will not intentionally expose themselves to.

    • Help youth craft discrete “exit strategies” to get out of conversations that may be triggering without having to disclose or reopen their own trauma issues.

    • Reinforce safety plans and support youth in attending to self-care to support resilience.

What Clinicians Need to Know

Suicide

In the first season of 13 Reasons Why, the protagonist, Hannah Baker, died by suicide in a highly graphic and controversial 3-minute scene (which was edited out from the Netflix streaming version on July 16, 2019). In season two, Hannah’s prominent posthumous role sent a confusing message to youth and detracted from the very real fact that suicide is forever. Also in season 2, another character, Alex, unrealistically survived a suicide attempt (self-inflicted gunshot wound to the head) with minimal physical disfigurement or cognitive sequelae. In season 3, while Hannah is no longer a central focus, there are still allusions to her suicide, as well as moments when other central characters contemplate suicide (i.e. Tyler stands on a bridge contemplating suicide and both Alex and Bryce make statements that they may be better off dead). The prevalence of youth suicide is steadily rising in the U.S. The majority of youth who attempt suicide have a significant mental health disorder, usually depression. While suicide is rare, clinicians need to know that:

  • Suicide is now the second leading cause of mortality among young people ages 10 to 24 in the U.S. surpassed only by accidents, according to the NIMH and  Center for Disease Control and Prevention (CDC).

  • The rate of suicide in teens is accelerating, according to CDC data. Between 2007 and 2014, the suicide rate among 15-19 year olds increased on average by 3.1% each year, and between 2014 and 2017, it increased on average by 10% each year.

  • The Youth Risk Behavior Surveillance Study (2017) of high school aged youth revealed that: 17.2% seriously considered suicide and 7.4% attempted suicide.

This same study showed that sexual and gender minority youth are at especially high risk. High school aged youth who identify as gay/lesbian or bisexual were much more likely to report having attempted suicide than peers who identified as heterosexual (3.2 to 3.6 times more likely in females and 3 to 5.5 times more likely in males). Teens who identified as transgender were 6.5 times more likely to report having attempted suicide compared with cisgender male peers.

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Clinicians can help in the following ways:​

School Violence

All three seasons of 13 Reasons Why have graphic depictions of violence above and beyond what a typical high school student would be exposed to season 1 ended with a harbinger of a horrific outcome when Tyler, depicted as a socially-awkward voyeur, purchased an arsenal of weapons and made a hit list of despised peers. Season 2 ended with Clay choosing to handle the acute threat of a school shooting on his own, without following standard protocols or involving authorities, and being depicted as heroic for doing so. Season 2 was released in the wake of two mass shootings and ongoing concerns about school safety across the United States. The #NeverAgain movement and the heartfelt cries for legislative action from teen activists echo still. In season 3, several characters threaten violence with a gun (i.e. Clay threatens to kill Bryce, Justin pulls a gun on his drug dealer, Tyler points a gun at Bryce). There are also several graphic depictions of physical violence throughout the season (i.e. two football teams fight during homecoming, Bryce deliberately and violently rams into Zach’s knee, Monty beats up a male peer at a party, and Bryce is viciously beaten and ultimately murdered). While most mental health providers will thankfully never interface directly with the outcomes of a school shooting, it is not uncommon to treat patients who have been impacted by serious physical assault and gun-related violence. Clinicians need to know:

  • Media coverage suggests that mass shootings, including school shootings, are common.  While they are certainly more common in the U.S. compared to other developed countries (Lankford, 2016), they are actually a small percentage of overall gun violence (Rozel & Mulvey, 2017).  Schools are and continue to be one of the safest places for children and adolescents to be (Cornell 2015).

  • Youth who have experienced peer violence (i.e. fighting, being threatened or injured, bullying) at school are more likely to bring a weapon to school (Pham, 2017). We do not know, however, if these youth are any more likely to commit a school shooting.

  • The most important thing to know about school shootings is that about 80% are preceded by warnings (Vossekuil, 2002).

  • Immediate threats of violence should be reported to 911 (or the emergency number in your country). 

  • Active shooter drills which are unannounced, graphic or explicit, or conducted without addressing the psychological impact on participants may be traumatic in and of themselves (Peterson et al., 2015)

 

Clinicians can help in the following ways:

  • Know specific risk and protective factors and learn how to perform threat assessments on students at risk for violence.

  • If you see something, say something. Encourage youth who have information about a threat to tell a trusted adult. Reports can be made to school leadership, local law enforcement, or through FBI-Tips.

  • Take threats or warnings seriously. Activate an interdisciplinary team to fully investigate every report. Additional helpful information can be found through the FBI’s Making Prevention a Reality report and the Association of Threat Assessment Professionals website.

  • Review the National Council for Behavioral Health’s report on Mass Violence in America with recommendations for health care organizations relating to the prevention of violence, violence risk management training, and rational approaches to school security.

  • Help your school by supporting the development of evidence-based threat management programs (Cornell 2018).

Sexual Trauma

All three seasons of 13 Reasons Why contain prominent themes related to sexuality. In season 1, there was confusing messaging related to sexual health and consent. In season 2, sexual assault became an even more prominent theme, with visual depiction of two additional graphic assaults (i.e. Jessica and Tyler) and flashbacks to Hannah’s sexual trauma. In season 3, characters attempt to cope with the aftermath of sexual assault through self-disclosure and activism around body autonomy. Sexual health is also a theme in season 3 as it pertains to abortion. When Chloe discovers she is pregnant by Bryce, she seeks an abortion. These scenes are emotionally charged as Chloe is confronted by pro-life protesters on her way into the medical center, and the abortion itself is depicted by showing Chloe’s face along with the background noises of the medical procedure. Individuals who have had abortions or who have been victims to sexual trauma may experience significant triggering by viewing dramatic portrayals, particularly those that include graphic imagery and highly emotional content. This can contribute to some youth developing significant posttraumatic, depressive and/or suicidal reactions. Furthermore, while the series does begin to suggest that help-seeking and psychotherapy can be helpful during seasons 2 and 3, there is much more focus on survivorship through public self-disclosure and seeking support from peers, as opposed to seeking out support from trusted adults and/or mental health professionals. Season 2 depicted Jessica attending group therapy, during which she discloses details of her trauma narrative. It is important to note that this is not a realistic portrayal of evidence-based trauma-focused psychotherapy. In season 3, Tyler attends weekly school therapy sessions with Dr. Singh, though there is no disclosure of or treatment of his sexual trauma. Also Bryce engages in individual therapy with former school counselor Mr. Porter which is clearly a problematic pairing given the conflicts of interest created by their past history. Finally, of note none of the scenes involving Jessica’s peer activism group, Hands Off Our Bodies, include mention of seeking guidance from mental health professionals. Clinicians need to know that:

  • It is important to screen all patients for history of trauma. Remember that youth with PTSD often present differently than adults. Since trauma-related symptoms overlap with other common childhood psychopathologies, there is risk for misdiagnosis (e.g. hypervigilance and dissociation, for example, could be mistaken for inattention). 

  • Consent is a core principle of sexual health. Sexual activity is not consensual unless the youth actively and without coercion, agrees to engage in a mutually understood and agreed upon activity at a specific time with a specific person.

 

Clinicians can help in the following ways:

  • Educate youth about consent (e.g. consider using this clever but effective video on consent) and healthy sexual behaviors.

  • Know your local resources for services geared towards victims of sexual trauma. RAINN (Rape, Abuse & Incest National Network) is the largest anti-sexual violence organization in the USA which has a provider locator and National Sexual Assault Hotline at 800-656-HOPE.

  • When a youth discloses recent personal sexual trauma, it is critical to guide them to prompt, specialized medical evaluation which will document and treat acute injuries, test for sexually transmitted infections, and advise about pregnancy and rape kits, etc. 

  • Locate local Children’s Advocacy Center where youth can receive specialized medical and psychological evaluation and referral to evidence-based treatment following sexual assault.

  • Locate therapists across the US certified in Trauma-Focused CBT (evidence-based treatment for youth sexual assault/abuse).

  • Be aware of evidence-based resources and support for trauma informed mental health care through the National Child Traumatic Stress Network.

Grief and Traumatic Grief

Death, related and unrelated to suicide, is another theme in all three seasons of 13 Reasons Why. In season 1, the series opened in the immediate aftermath of Hannah’s death by suicide. In season 2, Clay and peers continued to struggle with traumatic grief related to Hannah’s death. In season 3, there are several youth deaths, with a particular focus on the mysterious death of Bryce and the community’s complicated response. As discussed in the section above, in season 3, death and loss are also explored as it pertains to abortion. As clinicians are aware, grief is one of the most complicated experiences of the human condition. When sudden, unexpected death occurs, individuals must cope not only with the grief associated with the loss, but also with the shock of how they learned about it (e.g., inappropriately via the school PA system as in season 3), as well as, the potentially traumatic manner of the death, especially if it was particularly gory or shocking (e.g., suicide, homicide, mass shootings, accidents, etc.). Although youth tend to be resilient, some develop significant mental health difficulties including traumatic reactions that can lead to complicated grief responses (“traumatic grief”). For youth with traumatic grief, even happy thoughts of the person who died can lead to upsetting images of how they died. Furthermore, when a youth experiences a death, they may become curious about what death looks like (e.g., in seasons 3, Tyler took several pictures upon discovering Bryce’s body, and then found himself returning to those images in the days after). While this curiosity is not atypical, today’s youth have unsettlingly easy access to websites with graphic photos and videos of death via a simple web search. Imagined and actual images can be deeply unsettling for grieving youth, even when they volitionally sought it out. Youth often develop negative beliefs about the death (e.g., “I should have done something to prevent it”) and negative emotional states (e.g., depression, anxiety). Youth may also actively avoid thinking about or talking about the person, and any other cues that remind the youth of the person or the death. Traumatic reactions may exacerbate existing mental health issues, disrupt learning, and interfere with normal development. Clinicians need to know that:

  • Youth responses to death may vary depending on many factors, including peer and parental responses, prior traumas, level of support and preexisting mental health problems

  • Greater than 25% of youth who experience sudden deaths have significant mental health symptoms more than a year after the death; such youth could likely benefit from targeted interventions

  • Effective treatment is available for youth with traumatic grief

 

Clinicians can help in the following ways:

  • Be familiar with the signs of traumatic grief in youth 

  • Be aware of evidence-based instruments and screening questions that would indicate risk for prolonged grief in youth (Melhelm, 2013).

  • Screen high risk youth (e.g., those with a history of trauma, pre-existing mental health conditions, those who seem particularly avoidant about discussing the death or the person who died, or are exhibiting any concerning behaviors) for depression, PTSD and/or traumatic grief.

  • Provide educators with information about how to help youth after community trauma and respond after deaths that impact the school community

  • Refer identified youth to evidence-based treatment for traumatic grief

Substance Use

In seasons 2 and 3, substance use impacts the characters in a myriad of ways. Drugs of abuse in the series include alcohol, steroids, heroin, opioids, and cocaine. Themes include consequences of intoxication and withdrawal, as well as consequences of drug dealing. Arguably most problematic, is the dangerously unrealistic depiction of peers successfully detoxing Justin from opioids at home without medical intervention in season 2. In season 3, youth again attempt to handle Justin’s addiction without the help of adults by supplying him with oxycodone and advice that he try to self-taper. Clay does not tell his parents, nor does he encourage Justin to reach out to trusted adults despite Justin’s own acknowledgement that he likely needs to get professional help. Since only 1 in 12 youth who need treatment for addiction receive it (Han 2015), clinicians can play a critical role in working with families to prevent prescription misuse and detect substance use early. Clinicians need to know that:

  • The opioid epidemic is not just an adult issue. In 2015, 772 adolescents between 15 to 19 years of age died by a drug overdose (Curtin, 2017). Among the most statistically significant changes in opioid related deaths from 2015 to 2016 included a 33% increase in deaths among young people ages 15 to 24 (Seth, 2018).

  • The opioid epidemic is not just about substance use disorders, as opioids are increasingly being used in suicide attempts. The number of hospitalizations for intentional poisonings with prescription opioids in adolescents increased by 140% between 1997 and 2012 (Gaither, 2016).

  • The Monitoring the Future Study (2017) showed that among high school seniors, past-year heroin use continues to be uncommon, with a rate of 0.3%. Rates of any use of other opiates in the past year is 4%, which is a substantial decline in recent years. In contrast, rates of alcohol and marijuana use remain much greater.

  • Early intervention is key. The adolescent brain has increased vulnerability to the effects of substance use since it is still developing. Treatment can prevent progression to worsening patterns of use. According to NIDA, 25% of those who begin misusing prescription drugs by age 13 eventually develop a substance use disorder at some time in their lives.
     

Clinicians can help in the following ways:

  • Review the AACAP Substance Use Resource Center which has FAQs, handouts for families, rating scales and other clinical tools and resources.

  • Adopt the routine use of evidence-based screening tools that promote early intervention in clinical settings.

  • Encourage parents to keep open lines of communication and take time to listen to youth perceptions of substance use. It is critical that parents find a balance of both providing emotional support while also maintaining structure, including having rules and expectations.

  • Instruct parents to secure prescription medications in locked or hidden location and make sure families are conscientious about discarding any unused prescription medications including opioids, benzodiazepines, and stimulants.

  • Help parents to be on the look-out for any early warning signs of a substance use disorder in youth and seek professional help for teens if they are concerned.

Bullying

Throughout the entire series the implications of bullying are real. Bullying is defined by a power differential: a bully is very powerful, whereas a victim has little or no social power. This makes bullying different from other types of conflict, where the power of the two individuals is usually fairly even. There is also, the powerful social dynamic of the “third participant” in the dynamic: the bystander. Clinicians need to know that:

  • Bullying, aka peer victimization, is common. According to the CDC’s 2017 Youth Risk Behavior Surveillance System,19% of US students in grades 9-12 report being bullied on school property. The 2017 School Crime Supplement reported that 20% of US students ages 12-18 experienced bullying.

  • Cyberbullying is even more common, with as many as 40% of youth having experienced it.

  • Bullying, is a risk factor for mental health problems. Youth who have been frequently victimized are 3 to 4 times more likely to report suicidal ideation, and 2 to 3 times more likely to report a suicide attempt (Geoffroy, 2016).

  • Since both bullying victims and perpetrators are at elevated risk for suicide, a clinical assessment should be considered as part of any intervention for all parties (Holt 2017).

  • Research shows that bullied youth who feel cared for and connected to at least one adult or peer at school are less likely to feel suicidal than those who do not feel such connection (Hodges, 1999).

 

Clinicians can help in the following ways:

  • Be sure to screen for bullying and inquire about the nature of peer relationships, both in real life (i.e., “IRL”) and online.

  • Create individualized, practical plans that prepare a child to know: how to respond, how to get out of the situation, what they can tell themselves, who their safe person is, and where they can go for support.

  • Encourage youth to find ways to get more connected with peers (e.g. extracurricular activities).

  • Empower bystanders (those who witness bullying), whenever possible, to support the victim.

  • Involve law enforcement when necessary and securing evidence (e.g. screenshots) when available.

  • Familiarize yourself with the AACAP Resource Center on Bullying, as well as, other evidence-based online bullying resources and cyberbullying resources.

Research Outcomes from 13 Reasons Why:

The virally popular first season of 13 Reasons Why, which graphically depicted a fictional teen suicide over the course of a 3-minute scene, was watched by millions worldwide. Season 2 was also watched by millions, and it is estimated that 75% of viewers were adolescents or young adults. The show continued in popularity, and on the release date of season 3, the official trailer had been viewed more than 8.6 million times. While the series undeniably opens dialogues on sensitive topics that youth want to and need to understand (e.g. bullying, sexual assault, addiction, violence, suicide), the series is not without risk. On July 16th, 2019, following the publication of two epidemiologic studies demonstrating an increased rate of youth suicide in the months following the release of the show, Netflix chose to re-release season 1 with the three-minute suicide scene spliced out from the streaming service. The decision to remove the 3-minute graphic suicide scene two years after the release, however, does not eradicate risk. And thus, it remains crucial that clinicians educate themselves on the evidence-based findings regarding this controversial series.
 

In the aftermath of season 1, two key epidemiologic studies looked at CDC data to determine association between the show’s release and suicide rates. These studies found:

 

  • A 28.9% increase in death by suicide in U.S. youth aged 10-17 in the month immediately following the release of season 1 (incidence rate ratio: 1.29; 95% CI: 1.09-1.53). Furthermore, in the 9 months following the release, there were 195 more youth deaths by suicide than expected given historical trends (95 % CI: 168-22). This increase was not observed in 18-29 and 30-64-year olds, nor was it observed in homicide deaths for any age group. Stratification by sex revealed a statistically significant increase in suicide rates for boys aged 10-17 but not girls (Bridge et al., 2019).  
     

  • A 13.3% increase in suicide rates among U.S. youth aged 10-19 (but not aged 20+) in April-June following the release of season 1 (95% CI: 5.5%-21.1%). Further analysis of the data revealed a 12.4% (95% CI: 3.1%-21.8%) increase among boys and a 21.7% increase (95% CI: 7.3%-36.2%) among girls. This 3-month time frame corresponds to high rates of public engagement about the show on Twitter and Instagram. For the month of April 2017, this increase suggests 38.2 excess suicide deaths among 10-19 year olds (Niederkrotenthaler et al., 2019).

 

The observed association of an increase in youth suicide rates and the release of season 1 in both of these studies suggests that youth may have been vulnerable to the show’s portrayal of suicide. Of note, both of these studies only looked at suicide deaths and not nonfatal suicide attempts. The finding by Niederkrotenthaler et al. (2019) of a greater proportional increase of suicide in girls aged 10-19 is consistent with the prediction that girls may be more likely to identify with the female protagonist. However, when examining youth aged 10-17, Bridge et al. (2019) found a statistically significant increase in boys, but not girls. One possible explanation for this finding is that the male deaths could have reflected suicide contagion related to the male character Alex’s near fatal suicide attempt towards the end of season 1. It is possible that the females most negatively impacted by the show were the younger viewers (as is consistent with the findings in the Northwestern study) and subsequently, perhaps the female viewers at greatest risk for contagion might have had less lethal attempts.

 

Other studies examined the association between the release of season 1 and other trends. Some of the notable findings include:

 

  • A greater than predicted increase in admissions for self-harm with intent to die and suicidal ideation at a tertiary Children’s hospital following the release (Cooper et al., 2018)

  • A statistically significant rise in Crisis Text Line conversation volume on April 5th and 6th, followed by a 12.7% reduction in volume. This reduction was sustained for 49 days after the release, and is concerning in light of other research findings such as the increases in suicide rates, hospital admissions, and Google searches related to suicide (Thompson et al., 2019)

  • 900,000 to 1.5 million more suicide-related Google searches than expected in the 19-days post-release, including a 26% increase in queries on "how to commit suicide" (Ayers et al., 2017)

  • A statistically significant increase in emergency department presentation of youth with depression, mood, or suicidal ideation in the first 41-days post-release (Salo et al., 2017)

  • 13 out of 14 emergency departments with increased pediatric psychiatric volume and 40% reporting patients with 13 Reasons Why mimicry suicidal behaviors and/or attempts (Feuer et al., 2017)

 

Researchers also used questionnaires to investigate viewing patterns and the potential influence of the show on mental health outcomes, perceptions of suicide, and discussions with others.

  • A survey of college students found no statistically significant association between watching season 1 and suicidal ideation severity and suicide behavior risk, although had limited statistical power to detect these associations. This study also found that the show may be a potential platform for education on suicide, particularly for those without previous personal exposure (Chesin et al., 2019).

  • Another survey of over 7000 youth aged 12-18 years found that almost a quarter of respondents reported worsening mood after watching the first season, and this rate was significantly higher for those who reported suicidal ideation or a past suicide attempt (Rosa et al., 2019).

  • A survey of young adults aged 18-29 found that those who watched only part of season 2 expressed greater suicide risk than those who watched the entire season. Viewers who watched the entire second season also reported declines in suicidal ideation compared to those who did not watch the show at all, and were more likely than those who watched only part of season 2 to express interest in helping a suicidal person. Of concern, this study also found that only 51% of those who were aware of the second season saw the warning message at the beginning of season 2, and only 27% of viewers visited the prevention website featured at the end of each episode (Arendt et al., 2019).

 

In March 2018, Northwestern Center on Media and Human Development released results of an online survey of 1700 youth and parents examining perceptions of 13 Reasons Why.  While the investigators concluded that 71% of youth and young adult viewers indicated that the show helped them to process difficult topics;

 

  • 33% of youth and young adult viewers reported the content of the show was too graphic (with younger viewers and those with higher social anxiety especially sensitive to the content)

  • 43% did NOT agree with the statement that "the way the suicide was depicted was appropriate for me personally."

  • 18% of youth admitted that their parent did not know they were watching the show. Youth and young adults reported that they watched the show alone “always” (42%) or “most of the time” (28%).

 

Two key limitations of this study included: (1) the survey did not capture high-risk youth and thus potential dangerousness cannot be accurately assessed; (2) self-report of “improved understanding” of mental health issues, may actually represent “misunderstanding” since there was limited psychoeducation in the series and less than half of viewers sought additional information on sensitive topics after watching the series.

 

With regard to the first limitation, in February 2019 researchers at the University of Michigan published results of a similar survey, but this time administered to parent-youth dyads presenting at a psychiatric emergency department with suicide-related concerns (Hong et al., 2019). This study found that the show was widely known among these high-risk youth (10-17 years old), and

  • 84% watched it alone, and only 5% watched it with a parent.

  • While 80% of youth viewers talked to their friends about the show, only 34% talked to a parent.

  • 51% of those who watched the show agreed that it increased their risk of suicide.

  • Youth viewers who identified with Hannah or had an increase in negative affect from viewing the show were statistically significantly more likely to report that watching the show increased their risk of suicide

  • The number of youth who believed the show glamorized suicide was equal to number who did not, and overall the youth surveyed expressed more positive than negative sentiment about the show.

 

Comparing these findings to those from the Northwestern report, it appears that high-risk youth may have different viewing and discussion habits as compared to the general population. Specifically:

  • Only 34% of youth surveyed in Hong et al. (2019) discussed the show with a parent, compared to 71% of youth in the Northwestern survey

  • Only 5% of youth surveyed in Hong et al. (2019) in watched the show with a parent, compared to 39% of youth in the Northwestern survey

  • Only 25% of parents surveyed in Hong et al. (2019) discussed suicide with their child because of the show, compared to 73% of parents in the Northwestern survey

 

While many of these research findings are concerning, they were not unexpected. It is known from decades of suicide research that dramatic portrayals of suicide on screen can increase subsequent risk of suicide and suicide attempts using the same methods and usually within the first two weeks of exposure (Gould, 2003: Ladwig et al., 2012). This risk of suicide contagion (i.e. “Werther Effect” after Goethe’s novel The Sorrows of Young Werther which triggered a cluster of imitative suicides in 1774) occurs in a dose-specific fashion and is amplified in the absence of mental health information. Individuals at highest risk tend to identify with the suicide decedent and are more likely to have pre-existing vulnerability to suicide. Furthermore, the show’s producers had limited content depicting the distressed characters overcoming adversity through coping skills or positive adult supports. Thus, Netflix missed a chance to decrease the rate of suicide attempts (i.e. “Papageno Effect” after Mozart’s The Magic Flute regarding the effect that media can have by presenting non-suicide alternatives to crises). Overall, while more research is needed to explore the show’s effects on youth and elucidate explanations for the associated trends presented above, current research findings support an association of the show with increases in youth suicide and suicidal behavior, as well as concerns that high-risk youth may be differently negatively affected by the show’s content.

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