Last summer, Netflix’s show 13 Reasons Why caused public concern about the risk of suicide contagion among teenagers – particularly in those who have suicidal thoughts. The show portrays the suicide and aftermath of a teenage girl who documents her reasons for the suicide in a series of audiotapes. Psychotherapists, school social workers and teachers expressed apprehension about the show for apparently praising suicide and increasing suicide risk among teenagers who are isolated, struggling, or vulnerable to suggestive images and storylines. However, there is a lack of clear evidence for the influence of fictional content on self-harm. Responses to mental health concerns should be based on evidence not public anxiety. Marco Scalvini is a lecturer in the Global Dimension Program at LSE Enterprise, his research focuses on public health communication. He co-authored Why we must defend suicide in fiction in the British Medical Journal (BMJ). Flandina Rigamonti is a psychodynamic psychotherapist and counsellor working in private practice with individuals who present with depression and anxiety. She is a fully accredited member of UKCP, BACP and FPC. [Header image credit: W. Alzuhair, CC BY-NC-SA 2.0]

13 Reasons Why tells the story of Hannah Baker, a 17-year-old high-school student who commits suicide and leaves behind 13 tapes explaining why she chose to take her own life. The show provoked a heated debate over its portrayal of sensitive subjects such as teen suicide, self-harm, rape and bullying. The first season raised criticism for its graphic content, most notably the scene in which Hannah kills herself. Many educators and health professionals were critical of the depiction, warning that it could contribute to a contagion effect and linked the show to self-harm and suicide threats among young people.

News outlets, including The New York Times, reported anecdotal evidence that the series triggered “imitative” behaviours among high school students — for example, girls cutting their hair, painting their nails blue, or recording similar tapes. A study published by the JAMA Internal Medicine, found that Google searches for suicide — a potential marker of suicidal ideation — increased after the series’ release.

In the US, the Society for the Prevention of Teen Suicide claimed Netflix’s show “tends to glamorise and sensationalise suicide” and “may increase the relatability and identification a viewer may have with characters and/or situations”. Further, the US National Association of School Psychologists in a report said: “We do not recommend that vulnerable youth, especially those who have any degree of suicidal ideation, watch this series. Its powerful storytelling may lead impressionable viewers to romanticise the choices made by the characters and/or develop revenge fan.”

The panic of a risk of contagion led Germany’s Professional Association of Paediatricians to call for the “immediate cancellation” of the TV show. A joint statement issued by the German Society for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy and the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology reported that both organisations are confronted with an “increasing number of suicides which are directly related to the viewing of the series”.

The relationship between media portrayal and suicidal behaviours has been a subject of research for decades. However, current evidence in support of the belief that fictional media results in suicide contagion effects remains weak and a strict causality has never been established. The relationship between media and self-harm is not simply that of one-way cause-and-effect. As Sonia Livingstone has already noted, in many studies reflecting public anxieties over youth and media, “the claim of causality cannot be considered conclusive” because of various methodological and disciplinary inconsistencies. Even if we accept that media can have an effect, it is likely to be minimal and not sufficient to drive people to commit suicide.

Certainly, the media are a relevant agent in the construction of reality, especially in vulnerable teenagers and young adults, but the effect that fiction can have on suicidal thoughts and behaviours is probably smaller than that of other psychological and social risk factors for suicide. Further, the literature focuses mainly on non-fictional media reporting without making any distinction between individual vulnerability and the type of media portrayal. Thus little is known about variations in media effects with regard to audience vulnerability and story contents.

Can controversial content in 13 Reasons Why spark conversations and evoke empathy?

Fictional portrayals of suicide might empower vulnerable people in terms of normalising mental health issues, preventing suicidal ideation or encouraging help-seeking. It has been suggested that appropriate portrayals such as those emphasising negative consequences or alternative courses of action, could actually have a protective, or educative effect.

A recent study by Northwestern University funded by Netflix, Exploring How Teens and Parents Responded to ‘13 Reasons Why’, surveyed a sample of 5,000 adolescents and young adults, aged 13 to 22, and parents in the US, UK, Brazil, Australia and New Zealand, to determine how audiences perceived, related to and were influenced by the show. The data suggest that young adults and parents found watching 13 Reasons Why prompted conversations between teens and parents about bullying, suicide and mental health. Most importantly, the show led adolescents to show more empathy for their peers. The study also reported that parents and adolescents were interested in finding more information on the subject.

These results can help us identify relevant areas for further investigation. For instance: Why and how in particular did young viewers identify with the characters? What was overlooked? To what extent does the degree of realism affect viewers? What effect does the depiction of the consequences of the suicide have on viewers? Certainly, there is scope also for further research to analyse the longer-term effect that this TV show may have in terms of attitudes, thoughts and feelings in relation to suicide attempts, suicidal ideation, and acts of self-harm.

Unfortunately, the survey did not ask whether watching the show encouraged suicidal thoughts in viewers. According to Ellen Wartella, who led the research project, those questions were not approved by the Northwestern’s Institutional Review Board because interviewees would have required “support and expertise” to respond to them. Perhaps future research could also address those ethical implications, which are relevant to creating a better picture of whether the TV show prompted viewers to self-harm or had beneficial effects on self-harming behaviour, in terms of harm reduction and prevention.

What, then, can be done?

In response to the 13 Reasons Why controversy, The BMJ, in an editorial ‘Suicide on TV: minimising the risk to vulnerable viewers‘, called for better implementation of international standards on the depiction of suicide by film and television companies. According to the authors, the Netflix series could trigger “self-harm among vulnerable viewers by romanticising suicide and portraying it as the only option to cope with negative experiences”. For this reason it is argued that “clinicians need to be aware of heightened media attention to adolescent suicide and ask vulnerable young patients about possible exposure so that potentially harmful effects can be minimised”.

Responding to the criticism, Netflix created a downloadable viewing guide to help parents and teens talk about the show’s difficult themes. The second season also includes a new aftershow which features the actors, experts and educators who helped inform Netflix’s approach to the series. Those initiatives are laudable but it is not clear to what extent they will be effective without a proper study on audience.

Netflix’s attempt to provide support to vulnerable viewers should be led by evidence rather than public anxiety through a combination of thoughtful strategies which should be tested, refined and co-ordinated before being implemented. Evidence can also be used to support the demand that the government consults on and invests in mental health services for young people and that our educational system provides information and counselling on self-harm and suicide.

This post gives the views of the author and does not represent the position of the LSE Parenting for a Digital Future blog, nor of the London School of Economics and Political Science.