© 2018 13RW Work Group, an international coalition of leading experts in mental health, suicide prevention, and education.

Guidance For Clinicians

#13RWclinicians

Netflix released the second season of the controversial series 13 Reasons Why on Friday, May 18th, 2018. This section of the 13 Reasons Why Toolkit was developed by an international coalition of mental health experts with the intention to review the scientific literature as it pertains to the series, as well as, provide practical advice and resources to help 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. sexual trauma, suicide, violence), and if doing so, how to recognize and seek immediate help for negative reactions if they occur.

  • If teens do choose to watch the show, recommend they watch it with a parent and/or trusted adult.

  • Clinicians who work with teens 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

3

Promote help-seeking behaviors

  • In both seasons of 13 Reasons Why, adults are consistently depicted as incapable of listening or understanding.  It is critical that clinicians help teens 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 family members, school staff (e.g. Teachers, counselors, coaches, nurses, etc), and general medicine practitioners are primary gatekeepers to mental health services.

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

What Clinicians Can Do In Response to Season 2

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

4

Support for youth at risk:

  • Youth with histories of traumatic exposure to violence, school violence, suicide or sexual assault may be triggered by direct or incidental exposure to sensitive content on screens. Even a teen 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 them to set boundaries and limits about what they will and will not intentionally expose themselves to.

    • Help them 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 them in attending to self-care to support resilience.

What Clinicians Need to Know About Season 2

Suicide

The 13 Reasons Why protagonist who died by suicide in the first season, Hannah Baker, continues to play a prominent haunting and influential role in the second season.  Her ongoing presence in the storyline sends a confusing message to youth, and detracts from the very real fact that suicide is FOREVER. Furthermore, the catastrophic outcomes of surviving a serious suicide attempt is depicted unrealistically in the case of Alex, who not only survives a self-inflicted gunshot wound to the head, but has relatively minimal physical disfigurement or cognitive sequelae.

The prevalence of youth depression is steadily rising in the U.S. with 11.3% of teens reported having had a major depressive episode in 2014, as compared to only 8.7% in 2005 according to a National Survey on Drug Use and Health (N= 172,000). And while suicide is rare, clinicians need to know that:

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

  • The Youth Risk Behavior Surveillance Study (2015) of high school aged youth revealed that: 20% considered suicide, 17.7% seriously considered suicide, and 8.6% attempted suicide

 

Clinicians can help in the following ways:

School Shootings

​At the end of the first season of 13 Reasons Why, Tyler, who is depicted as a socially-awkward voyeur, had purchased an arsenal of weapons and made a hit list of despised peers suggesting the harbinger of a horrific outcome. In the second season, the teen protagonists ignore standard protocol by choosing to handle the acute threat of a school shooting on their own without involving authorities, and are depicted as heroic for doing so. Season two was released after 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. According to a 2014 FBI report, there were, on average, 16.4 mass shootings a year from 2007 to 2013, and schools and universities account for one-quarter of these. While most mental health providers will never interface directly with such devastation, 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.

  • 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 youths 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). 

Clinicians can help in the following ways:

Sexual Trauma

The second season of 13 Reasons Why contains prominent themes related to consent, sexual trauma, and physical violence. Teens who have experienced sexual or other trauma may experience significant trauma reminders (“triggering”) by viewing dramatic portrayals of sexual trauma, particularly those that include graphic imagery and highly emotional content. This can contribute to some teens developing significant posttraumatic, depressive and/or suicidal reactions. Furthermore, the series does suggest that psychotherapy can be helpful, but unfortunately, the depiction of the intervention (during which Jessica discloses details of her trauma narrative in a group setting), was not a realistic portrayal of evidence-based trauma-focused psychotherapy. Clinicians need to know that:

  • Educate sexually active youth about consent (e.g. consider using this clever but effective video https://www.youtube.com/watch?v=fGoWLWS4-kU) and healthy sexual behaviors.

  • Be sure 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 teen 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 sexually active youth about consent (e.g. consider using this clever but effective video (https://www.youtube.com/watch?v=fGoWLWS4-kU).

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

  • When a teen discloses recent personal sexual trauma, it is critical to guide them to prompt, specialized medical evaluation (https://rainn.org/articles/receiving-medical-attention) 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 teens can receive specialized medical and psychological evaluation and referral to evidence-based treatment following sexual assault: http://www.nationalchildrensalliance.org/

  • Be aware of evidence based resources and support for trauma informed mental health care (https://www.nctsn.org). Locate therapists across the US certified in Trauma-Focused CBT (evidence-based treatment for teen sexual assault/abuse): https://tfcbt.org/members/

Substance Use

In season 2, substance use impacts the characters in a myriad of ways. Since only 1 in 12 youth who need treatment for addition 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 because the adolescent brain has increased vulnerability to the effects of substance use since it is still developing, and because treatment can prevent progression to worsening patterns of use. According to NIDA, 25% of those who begin abusing prescription drugs by age 13 develop a substance use disorder at some time in their lives.
     

Clinicians can help in the following ways:

  • Encourage parents to keep open lines of communication, take time to listen, and provide emotional support while maintaining structure, including having rules and expectations.

    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.

  • Encourage parents to be on the look-out for any early warning signs of a substance use disorder

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

Bullying

​In season 2, 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, affecting more than 1 in 5 youth (Lessne 2016). Cyberbullying is even more common, with as many as 40% of youth reporting having experienced it.

    Bullying, is a risk factor for mental health problems. Teens 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.

 

Clinicians can help in the following ways:

  • 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 and others with 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. While the series undeniably opened dialogues on sensitive topics that teens want to and need to understand (e.g. bullying, sexual assault, substance use, physical violence, suicide), the series was not without risk.
 

Early analysis of the first season of 13 Reasons Why revealed:

 

  • 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 (Salo, 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, 2017)

 

While these findings are concerning, they were not unexpected. It is known from 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 (a.k.a the “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 little content depicting any of the distressed characters overcoming adversity through coping skills or positive social supports. Thus, Netflix missed a chance to decrease the rate of suicide attempts (a.k.a the “Papageno Effect” after Mozart’s The Magic Flute) too.

 

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 teen and young adult viewers indicated that the show helped them to process difficult topics;

 

  • 33% of teen 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 teens admitted that their parent did not know they were watching the show. Teens 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.

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