A review of new evidence on the impact of '13 Reasons Why'

by Liesje Donkin
in News
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New research has found the release of 13 Reasons Why was associated with an increase of suicide rates among US youth aged 10-17 years resulting in an estimated 195 additional suicide deaths in 2017 for 10-17-year olds.  Subsequent to the release of this research Netflix has announced (mid July 2019) that more than two years after the first season of 13 Reasons Why was first streamed in 2017, a graphic scene depicting the suicide of the main female character has been cut from series one, ahead of the release of series three.

This series tells the story of a teenage girl called Hannah Baker who leaves behind 13 audio recordings after killing herself.  The series is based on a book by Jay Asher, and whilst in the fictional book the suicide is only mentioned briefly, in contrast in the Netflix series, the suicide was shown graphically and in what has been described as “brutal and explicit detail” lasting 3 minutes (#1).

When season one of the Netflix series was first streamed in March 2017, international concern was immediately raised arguing that the series ignored or overlooked evidence and media guidelines on the portrayal of suicide and that there was potential to increase suicidal behaviour in those vulnerable populations watching the show (#2-3).  Netflix were advised of the safety risks by mental health experts prior to the release of the show and were advised not to release the show at all and certainly to remove the suicide scene (#4).  Netflix also ignored international media guidelines (e.g. WHO, 2017; Mindframe, 2007; Ministry of Health, 2011) around the portrayal of suicide in media (including newspapers, TV, radio and more recently social media) and representation of suicide in the entertainment industry

Recommendations include:

  • avoid providing graphic visual imagery of the method of suicide for the main character
  • portray positive help-seeking
  • avoid presenting suicide as a means of revenge or a goal (Hannah Baker suicides to seek revenge in the show)
  • avoid glorifying and romanticising the main character who suicides
  • provide suicide prevention resources

In contrast to these above recommendations, 13 Reasons Why:

  • played three whole minutes of the detailed and graphic suicide imagery as Hannah Baker killed herself and died
  • portrayed school students mainly having negative help-seeking experiences, with both parents and school guidance counsellors
  • portrayed suicide as a means of revenge for Hannah
  • glorified and romanticised the lead character Hannah who died,
  • failed to provide suicide prevention resources. Initially there was only one warning which appeared before the initial episode.  It was only a month later that a warning was added about the series as a whole and again this only appeared before the initial episode.  By that stage, many young people had binge watched the entire season.

However, there was also a differing perspective which supported the 13 Reasons Why series as it allowed conversations about suicide to emerge. A New Zealand Herald article at the time (dated 8 May 2017) (#5) quoted the series creative manager Brian Yorkey as saying he saw the show as a success because it was opening conversations about suicide:

"Of course, the fact that we're even having these discussions speaks of real progress to me," he wrote, comparing the 'silence equals death' slogan that surfaced in the 1980s with the rise of the HIV/AIDS epidemic to teen suicide.

"When it comes to suicide, I believe the message should be exactly the same. Facing these issues head-on - talking about them, being open about them - will always be our best defence against losing another life."

Yorkey also believed that portraying the suicide in graphic detail would help rather than be considered dangerous.

"It overwhelmingly seems to me that the most irresponsible thing we could've done would have been not to show the death at all. In AA, they call it playing the tape: encouraging alcoholics to really think through in detail the exact sequence of events that will occur after relapse. It's the same thing with suicide. To play the tape through is to see the ultimate reality that suicide is not a relief at all - it's a screaming, agonising, horror”.

When the series was first streamed, anecdotal evidence began to emerge that suggested young people had been watching the series prior to engaging in suicidal behaviour.  Professor Ella Arensman (co-chair of the IASP Cluster and Contagion Special Interest group) was one of those gathering anecdotal evidence which indicated suspected suicides in the USA, Austria and Peru were copycat deaths or directly related to 13 Reasons Why. 

This research by Bridge and colleagues (2019) was the first substantive research that looked at the association between the release of the Netflix series 13 Reasons Why and suicides rates in the United States.  The researchers tracked US suicide rates amongst all ages (10-64 years) for the four years from January 1, 2013 to December 31, 2017.  13 Reasons Why was released March 31, 2017.  The data was collected both before the release of the series and for a 3-month period following the release. The focus of their study was to identify if there were any associations between increased suicide rates amongst different ages and genders following the release of series one of 13 Reasons Why.   The data was analysed by age (age groups 10-17 years, 18-29 years and 30-64 years) and gender. 

The key findings were:

  • the suicide rate among 10-17-year olds increased significantly in the month following the release of 13 Reasons Why.
  • there were no significance changes in the 18-29- and 30-64-year age-groups
  • Rates of suicide in the 10-17-year age group were elevated in the month after release of the series and in the subsequent 2 months. The series was released on March 31, 2017 and the number of suicides recorded in April 2017 was greater than the number seen in any other single month during the 5-year period of the research.
  • The research authors estimated that the series release was associated with approximately 195 additional suicide deaths in 2017 for 10-17-year olds.
  • Rates of suicide were elevated for both teen boys and girls after the release of the show but only statistically significant for teen boys

The findings need some caution as the authors note they are not able to make causal conclusions about the increased suicide rates however credible inferences about the association can be made.  They also recognise the difficulty in identifying whether the increase in suicide rates was due to:

  • the portrayal of suicide in the series
  • the lack of best practice following media guidelines e.g. failure to provide national suicide prevention resources until later months, graphic visual imagery of the method used, glorifying suicide, not promoting successful help-seeking behaviour
  • other factors e.g. the impact of pre-release promotion of the series premiere

An unexpected finding was gender difference with the suicide rates only being statistically significant for teen boys. Given the main character who died by suicide in the show was a girl, it was anticipated that the rates of suicides for teenage girls would increase given suicide contagion is often a result of strong identification of the person who died by suicide.  The reasons this was not found as expected are potentially due to three possible reasons:

  1. the male adolescent character who made a serious suicide attempt by firearm at the end of the series may have been a key identification figure for many male youth (he was also gay so it would be interesting to know if this was a sub population of those male youth who died by suicide after the series).
  2. while male rates of suicide are higher than female rates, female rates of attempted suicide are higher than males. The rates of attempted suicides by teenage girls after the show may have elevated also but this information was unable to be collected nationally.  One single hospital study did show an increase in suicide attempt admissions in the month following the release (#4).
  3. The series was based on a book which was published over a decade ago and re-released in 2016. There may have been some degree of desensitization to the content by high female readership prior to the series release.

This study is important as it provides evidence of an association between portrayals of suicide within the entertainment industry and increased suicide rates which supports the concerns expressed by many prior to the release of 13 Reasons Why.   The portrayal of suicide in television drama’s, theatre and film is widespread and it is reported these depictions are becoming more graphic, lengthier, and more sensationalised (#7).  Resources specifically targeted to the entertainment industry have been developed such as those by Mindframe aimed at stage and screen content creators. This resource explores both the way suicide and mental illness in general is portrayed. A more recent publication with specific guidelines for the entertainment industry, National Recommendations for Depicting Suicide has been the result of collaborative efforts the National Action Alliance for Suicide Prevention, SAMSHA and the Entertainment Industries Council. This resource is aimed to help members of the entertainment industry (content creators, scriptwriters and producers) tell more authentic and balanced stories involving suicide and suicide prevention and has nine recommendations as follows:

  • Convey that suicide is complex and often caused by multiple factors.
  • Show that help is available.
  • Portray characters with suicidal thoughts who do not go on to die by suicide.
  • Connect viewers to resources.
  • Portray everyday characters who can be a lifeline.
  • Depict the grieving and healing process of people who lose someone to suicide.
  • Avoid showing or describing the details about suicide methods.
  • Consult with suicide prevention messaging experts and people with personal experience.
  • Use non-judgmental language.

Issues related to portraying suicide in the entertainment industry are also seen here.  A recent example was in June 2019, the Shortland Street soap opera explored the concept of “legal euthanasia” with a popular character with dementia choosing suicide.  The TV producers argued that it was an important conversation to have whilst Mental Health Foundation CE Shaun Robinson said he was “deeply disappointed” to see suicide on the show, their lack of consultation on the best way to depict suicide, and their nonadherence to media guidelines (#9) (e.g. the method was clearly depicted on the show).  

The research findings of Bridge and her colleagues (2019) highlight the potential impact the entertainment industry can have on suicidal behaviour in those who are vulnerable and being entertained, in particular the need to be cautious in the portrayal of suicide to a younger audience.  There are guidelines specific to the entertainment industry to inform ways of depicting suicide that can minimise the significant risks but also contribute in potentially positive way such as depicting suicidal behaviour that cultivates hope by increasing awareness of the supports available for those struggling (#10).  Research indicates that non- fictional accounts of individuals coping with suicidal thoughts, modelling resilience and seeking help with distressed may reduce suicidal behaviours (#11) but this has not been tested in fictional accounts yet. 

Two years after its premiere, the graphic suicide scene has been cut from the series 13 Reasons Why.  The show’s producers stated they were mindful of the ongoing debate and were taking advice from medical experts and decided to edit the scene.  The American Foundation of Suicide Prevention calls this edit a “positive change” that mitigates “the risk for the most vulnerable teenage viewers”.  Whilst Netflix must be applauded in finally removing the scene, is this simply “too little, too late” especially considering their decision to go ahead with Season 3.

Resources

  1. https://www.casa.org.nz/news/262-13-discussion-points-for-whanau-caregivers-or-professionals-concerned-about-13-reasons-why
  2. https://www.casa.org.nz/news/276-season-2-13-reasons-why
  3. https://www.mentalhealth.org.nz/get-help/13-reasons-why/
  4. https://www.leva.co.nz/news/13-reasons-why-we-must-at-least-do-no-harm

Guidelines

  1. Mindframe (2007) A Mindframe resource for stage and screen. Commonwealth of Australia. ISBN 1-74186-414-3 #8 https://s3-ap-southeast-2.amazonaws.com/mindframemedia/assets/src/uploads/Stage_and_Screen_Resource_Book.pdf
  2. National recommendations for Depicting Suicide #10 https://theactionalliance.org/messaging/entertainment-messaging/national-recommendations
  3. Ministry of Health (2011) Reporting Suicide: A resource for the media. Ministry of Health, New Zealand. https://www.health.govt.nz/publication/reporting-suicide-resource-media
  4. World Health Organisation (2017). Preventing suicide: a resource for Media professionals.  Update 2017. Geneva: World Health Organization. https://www.who.int/mental_health/suicide-prevention/resource_booklet_2017/en/

Opinion pieces and articles

Why that 13 Reasons Why scene took 2 years to cut: Inside the decision to edit the controversial series. The Atlantic. By Sophie Gilbert. July 19, 2019. 

https://www.theatlantic.com/entertainment/archive/2019/07/netflix-suicide-scene-13-reasons-why/594166/

Saint-Louis C. For Families of Teens at Suicide Risk, 13 Reasons Why Raises Concerns. The New York Times 

https://www.nytimes.com/2017/05/01/well/family/for-families-of-teens-at-suicide-risk-13-reasons-triggers-concerns.html

Koplewicz, H. 13 Reasons Why Spreads Suicide like a Disease: Column 

https://www.realclearpolitics.com/2017/05/06/03913_reasons_why039_spreads_suicide_like_a_disease_409545.html

13 Reasons Why Cuts Suicide Scene. What took them so long? By Linda Maleh.  Forbes. July 17, 2019. 

https://www.forbes.com/sites/lindamaleh/2019/07/17/13-reasons-why-cuts-suicide-scenewhy-its-long-overdue/#68070fc64687

Netflix renews 13 Reasons Why for second season 

https://www.nzherald.co.nz/entertainment/news/article.cfm?c_id=1501119&objectid=11851413

Shortland Street 'felt it was timely' to revisit death with dignity, Mental Health Foundation disagrees

https://www.stuff.co.nz/entertainment/tv-radio/113635498/shortland-street-felt-it-was-timely-to-revisit-death-with-dignity-mental-health-foundation-disagrees

References

  1. Bridge, J., Greenhouse, J.B., Ruch, D., Stevens, J., Ackerman, J., Sheftall, A. H., Horowitz, L.M., Kelleher, K.K., & Campo, J.V. (2019) Association between the Release of Netflix’s 13 Reasons Why and Suicide Rates in the United States: An Interrupted Time Series Analysis. Journal of American Academy of Child and Adolescent psychiatry. #6 https://doi.org/10.1016/j.jaac.2019.04.020
  2. Philips, D.P. (1982) The impact of fictional television stories on US adult fatalities: New evidence of the effect of mass media on violence. American Journal of Sociology, 87, 1340-1359. #7
  3. Niederkrotenthaler, T, Voracek, M., Herberth, A et al (2010). Role of media reports in completed and prevented suicide: Werther v Papageno effects. The British Journal of Psychiatry: the journal of mental science, 197 (3), 234- 243. #1

- Sandra Palmer, Clinical Advisor for CASA